Kenny Reference

Data= TemplateImgs<= /tr> <= /tr>
*** Resources: TWDFMR.

= **Admission UCI Workflow
SPPO Hospitalis= t Admission Sheet.xlsx (sharepoint.com)

Transfer Center Notes

Transfer Center: 714-456-2222
- caloptima= : inpatient (no obs) - "straight medical" also inpatient, even if not= meeting inpatient criteria

H&P Template Simple.docx

MGH Whitebook 2021-2022.pdfh ta= d

NF list

= ED to ortho-trauma-medicine agreement

Review Exam - StatRad Client Portal

- cardiology telemetry: new HF= rEF without other major comorbidities

- HELP orde= r for pharmacy help inpatient

- ROS: fever, dizzy, CP, SOB, abd p= ain, dysuria, freq, constipation.

- PMH/PSH:

- FamHx:

=
- Living:
- ADL:

- Code:
- dPOA:

- PE:

<= td class=3D"oa3" width=3D"374" style=3D"width: 187pt;">

=C2=B7 Invasive central venous, PA, ICP= , A line, bladder pressure

=C2=B7 Q1 hr monitoring

=C2=B7 1:1 or 2:1 nursing ratio

<= td class=3D"oa4" width=3D"290" style=3D"width: 145pt;">

=E2=96=AA BiP= AP PRN

=E2=96=AA High flow

=E2=96=AA Matu= re trach, vent

=C2=B7 Stable chronic atrial arrhythmia a= dmitted for unrelated reason and hemodynamically stable

=C2=B7 Asymptomatic stable = sinus bradycardia

=C2=B7 Asymptomatic Wenckebach

=C2=B7 Chronic stable heart failure=

=C2=B7= Chronic = PACs/PVCs

=C2=B7

ICU
<= /p>

Stepdown (56,68,44)

Teleme= try (DH78, 66, T5, T3,B3)

Monitoring

=C2=B7 Q2hr monitoring

=C2=B7 Q1hr monitoring not to exceed = 6 hr

=C2=B7&nb= sp;3:1 nursing ratio

=C2=B7 Q4hr vitals

=C2=B7 Q1-2hr monitoring not to exceed 6 hours

=C2=B7 4:1 nursing ratio

MedSurg (T4= )

=C2=B7 5:1 nursing ratio

=C2=B7 Pulse oximetry

=C2=B7 Q1-2hr monitoring not to exceed 6 h= ours

Medications

=C2=B7 Titration of IV vasopressors

=C2=B7 IV anti-arrhythmic meds<= /p>

=C2=B7<= /span> Systemic = thrombolytic rx

=C2=B7&= nbsp;Fluid replacement > 6L/day

=C2=B7 Insulin gtt

=C2=B7 Non-titratable gtts if hemodynamically stable: diltiazem

=C2=B7 No moderate sedat= ion

=C2=B7 Non-titratab= le gtts:

amiodarone, lasix, PCAs

=C2=B7 IV Remodulin or CAD (3T)

=C2=B7 IV anti-hypertensive= s

= IV Haldol

=C2= =B7 Any g= tt for comfort measures

=C2=B7 Heparin

Airway

=E2=96=AA Ventila= tor

=E2=96=AA Fresh trach

=E2=96=AA QHS BiPAP

=E2= =96=AA Continuous BiPAP

=E2=96=AA Mature trach, no vent

=E2=96=AA High flow

Technology

<= span style=3D"font-family: Symbol; font-size: 9pt;">=C2=B7 Ext/transvenous pacemaker=

=C2=B7 M= echanical ventilation

=C2=B7 IABP or VAD

=C2=B7 Balloon tamponade varices

=C2=B7 CRRT

=C2=B7 Long Term mechanical ventilatio= n (mature trach and stable resp status)

=C2=B7 Neuro SDU (DH 56): Clamped ventricu= lostomy

=C2=B7= New pace= maker/ICD

&nb= sp;

Medical Condition

=C2=B7 Vitals: HR<40 or HR>140

SBP<80 or SBP>= 250

DBP<40 or DBP>130

=C2=B7 Labs: Hb<5, Na<120, Na>160, pH<7.2, K>6 + symptoms/EKG,&= nbsp;Gluc<40 for >2hr,=

2&l= t;50 on >50% FiO2,

pCO2>70 + pH<7.3 + AMS

=C2=B7 Conditions: status epilepticus, septic = shock, re= sp distre= ss, cardiac arrest, unconscious, ruptured viscera, uncontrolled hemorrhage,= unstable cervical fracture, acute stroke, unstable PE, symptomatic arrhyth= mias, ang= inal ches= t pain, severe multiple traumas, multiple unfixed long bone fractures, majo= r burns, inhalation injury

=C2=B7 New onset atrial arrhythmia or unstable chronic atrial arrhythmi= a

= Specialty surgical care: CT surgery, post kidney transplant, post-op <= /span>trachs

=C2=B7 Insulin&nb= sp;gtt<= span style=3D"font-family: Calibri; font-size: 9pt;"> with stable = ;gluc and Q2hr checks

= =C2=B7 Te= lemetry level of care but beds are full

=C2=B7 Syncope

=C2=B7 Arrhythmias

=C2=B7 New onset Atrial arrhythmia (stable= )

= AV block (Mobi= tz 2 or 3= rd)

= =C2=B7 Ch= est pain r/o

=C2=B7 Acute CHF exac

=C2=B7 Pre/post-cath

=C2=B7 Stroke

=C2=B7 Major surgery

=C2=B7 Severe K and Mag abnl

=C2=B7 Overdose c/b arrhyth= mias

=C2=B7&nb= sp;Loading of antiarrhythmic meds

=C2=B7 QTc prolongation

=C2=B7 IV nodal blocking agents

UCI Telemetry orders:

- Acute resp failure (48 hr)

- Chronic CHF (24 hr)

- Acute PE (48 hr)

- Sepsis (48 hr)

- Cardiology or CT surgery service (ongoing)

Rev= iew at 24 hr:

- Chest pa= in (low risk)

- Drug OD = or toxins with arrhythmias (72 hr)

- Severe electrolyte abnl (48hr)

- Major surgery

- S/p arrhythmia ablation

- S/p AICD firing

- = S/p PM or AICD placement

- IV beta-block or CCB

Review in 48 hours:

- ACS

- 2nd or 3rd degree AV block

- Cardiac contusion

- Chest pain (int-high risk)

- Acute CHF exacerbation (72 hr)

-= Initiation/titration anti-arrhyth= mic meds (72 hr)

- Myoca= rditis/pericarditis

- Ne= w onset or uncontrolled tachyarrhythmia

- Thoracic surgery

- NSVT

- Acut= e stroke (cryptogenic 7 days)

-= Syncope of cardiac origin

- Temp PM or transcutaneous pacing pads

- Use of QT prolonging medications

Not indicated:

- = Anemia not requiring massive transfusions

- Chronic stable atrial fibrillation

- Chronic PACs/PVCs

- Febrile illness, sepsis without shock

<= div>- GI bleeding not requiring ma= ssive transfusions

- H/o= CHF without current exacerbation

- H/o PM or AICD without malfunction or firing

- Respiratory illness without underlying c= ardiac disease

- Stable = PE without hemodynamic instability

- anti-smooth,= anti-dsDNA =3D lupus
- anti-U1-RNP =3D mixed connective tissue (=3D bot= h lupus, autoimmune myositis, and systemic sclerosis)
- anti-centromere = and anti-Scl-70 =3D systemic sclerosis (raynaud); CREST
- antiLa, anti-R= o - sjogren
- antihistone =3D drug induced lupus
- cANCA / antiPR3=3D= granulomatosis with polyaniitis (wagener)
- pANCA/anti-MPO - eosi= nophilic granulomatosis with polyaniitis
- anti-Jo1 =3D polymyositis
= - antiCCP or RF =3D rheumatoid

At VA: ANA panel reflexes to ANA IFA SCREEN
ANA IFA TITER
ANA IFA PRIMARY PATTERN
ANTI JO-1
ANTI SM
ANTI RNP
ANTI SM/RNP
SS-A
SS-B
SCLERODERMA AB (SCL-70)
RIBOSOMAL P PROTEIN AB
CENTROMERE ANTIBODY
CHROMATIN
ANTI DS-DNA

-methylene blue also for low BP ICUabdominal pain
- DDx: PUD, Hyplori,&nb= sp; IBS, gastropathy, celiac disease, MSK, mesenteric ischemia, SIBO, dyspe= psia.

GI = cocktail with maalox, viscous lidocaine, donnatol
adequate bowel regimen= , miralax, senna daily to bid
PPI daily
Avoid anticholinergics/ opiat= e medications
zofranachalasia
- barium swallow show bird's beak- need CT chest and abd to rule out cancer first (pseudoachalasia)

#Concern for achalasia= : CT with clear air fluid level suggestive of advanced disease. Chara= cterized by sensation and regurgitation x 2 years. ROS positive for GERD, w= eight loss, aspiration

- Barium esophagram t= o assess emptying, diameter, contour, and epiphrenic diverticula that may n= ot be appreciated on endoscopy

- EGD tomorrow to exclude eo= sinophilic esophagitis or other infiltrative disorders for pseudoachalasia = rule out

- Will need esophageal manometry fo= r gold standard for diagnosis of achalasia -- instructions and follow up in= structions to follow pending EGD and barium esophagram. Achalasia can be su= bclassified into 3 types based on results with type II being very responsiv= e to therapy, whereas type I may need endoscopic dilation.

- Most patient react well to disruption of the LES for remov= al of esophageal outlet barrier: botulinum toxin injection, pneumatic dilat= ation ,Heller myotomy, POEM, stent placement, esophagectomy

<= /div>

- Nifedipine 10-2 mg sublingual prior to meals, limited by SE of = HA and dizziness as well as a tachyphylaxis effect.

- Phosp= hodiesterase inhibitors for short term use

-= Medications can be used as bridge to sphincter disruption

Do interventions give her full= or partial improvement? Duration?

Eckardt s= core

0 =3D never

1 =3D occassional

2 = =3D daily

3 =3D with every meal

Dysphagia =E2=80=93 both solids and liquids? Types of foods

Regurgiation =E2=80=93

Chest pain =E2=80=93 locatio= n, quality? spasm? Occurs with or without meal?

Weight loss =E2= =80=93 <5, 5-10, >10 kg

Total possible score is 12

acidosis

ACLS - asystole / cardiac arrest
1) CPR all cases
PEA/asystol= e: epi 1mg q3-5m
pulseless VT/VFib: defib with biphasic 120-200J, then e= pi 1mg q3-5m / amio 300mg 1st dose, 150mg 2nd dose (or lidocaine 1-1.5mg/kg= 1st dose, 0.5-0.75mg/kg 2nd dose)
If Torsade 1-2g MgSO4 over 15 min
= pulse check q2m
HyperK - Ca gluco 2g IV (or CaCl2), BiCarb 1-2amp IV, in= sulin 10u, D50 1-2amp
Naloxone: 2mg IV if pulseless. If puse, 0.2-1mg IV=

- add capnography, peek EtCO2 > 10mg, ideally > 20
- if su= spect PE and pulseless =3D tPA 50mg IV/IO over 2 minutes, can repeat = 50mg IV/IO in 15m; if pulse, 100mg infusion over 2 hours
(contraindicate= d if prior ICH, ischemic CVA or head trauma within 3 months, known brain ca= ncer, suspected aortic dissection or active bleed)

prognosticate: ET= CO2 < 10mg in intubated after 20 minutes =3D 90% sensitive no ROSC
pr= egnant: left lateral uterine displacement

- TTM if comatose cardiac = arrest followign ROSC (GCS < 8, not following commands, no purposeful mo= vement to stimuli) (contraindicated in major head trauma, major surgery wit= hin 14d (increases risk of infection), active bleeding (causes hypercoag), = sepsis, coma from drug

*** -- if pulseVtach or Vfib, shock first -&n= bsp; giving epi will sustain the arrhythmia more likely. (2 shocks be= fore epi).

Reversible causes:
- hypovolemia, hemorrhage, = hypoxia, acidosis, hypo/hyperK, hypothermia, thrombosis, ACS, PE, tension p= neumo, tamponade, toxins (drugs)- ABG
- CBC
- CMP
- lactate
- INR/PT/PTTfibrinogen/= D-dimer,
- trop
- EKG
- SpO2 > 92%
- MAP > 65, levophed i= f needed

- CT head if concern for ICHACLS / RRT - Brady (symp= tomatic) HR <50
- PE: warm/cold, pupils
- review EKG, med ch= anges, labs
- Labs: BMP, Mg, Lactate, Drop
- Hold BB and antiHTN
-= atropine 1mg q3m x3 max (avoid if 2nd degree type 2, 3rd degree bloc= k and do not do less than 0.5mg as slows HR even more), then dopamine= 5-20mcg/kg/min or epi 2-10 mcg/min
- if pacing, Versed (midazolam) 0.5-= 2mg, max total 5mg, repeat q2-5m + fentanyl 25-50mcg q5m. (1mg Versed + 25m= cg fent normally by Cardiology)
- DDx:
- beta blocker, give g= lucagon 5mg IV bolus, repeat x2 (if responding, 5mg/h)
- Calcium = blocker: glucagon per above (increases cAMP) + calcium gluconate 60mg/kg (m= ax 6g/dose) over 5 minute, repeat in 10m x3 additional, insulin 1u/kg bolus= ; order serial Ca lab and EKG to prevent high Ca
- opioid: naloxo= ne 0.8mg IV
- cause: meds, SSS, hyperK, ischemia/ACS, vagal, elderly, en= docarditis/lyme/viral carditis, elevated ICP, infiltrative disease, hypothy= roid, nocturnal only (in athletes)<= /tr>ACLS / RRT - Tachy (symptomatic)
- consider: time cour= se, Hx, where the reading was from, baseline, meds and held meds
- manag= ement:
1) BP stable? if not cardiovert
2) symptomatic: = fluids, diuretics, electrolyte, antipyretic, rate control
3) reve= rsible causes: recent meds or not given
4) bedside echo for R hea= rt, tamponade, IVC size, pneumothorax
5) Escalate if hypotensive = or need drip

- Causes:
- cardiac: HF, MI= , tamponade, Afib/aflutter, SVT, VT
- non-heart: PE/DVT, hemorrha= ge, infection, hypovolemia, electrolykte (K, Mg), drugs/med withdrawal hype= rthyroid, pain/anxiety
- PE: warm/cold, murmur, pulm edema
- review E= KG, labs
- EKG
- if hypotensive shock, AMS, acute HF/pulm edema, ches= t pain: sync cardioversion (100J if narrow reg (if aflutter 50J), 120-200J = if narrow irre (Afib needs 150J), 100J if wide red, DEFIB 120-200J if wide = and irregular)
- narrow regular: vagal -> adenosine -> IV BB or di= lt 0.25 mg/kg)
- narrow irre: IV BB or dilt
- wide regular: ami= o 150mg IV over 10 min, repeat x1 (1mg/min x6h, 0.5mmgx18h) --> lidocain= e (lido 1mg/kg 1st dose, 2nd 0.5 mg/kg)
- wide irregular Lido + 2g Mg ov= er 15 min

!!No dilt if HFrEF

- Vagal: tried carotid mas= sage, if doesn't work, head of bed 45, then blow syringe 15 seconds, then f= lat and raise legs 45 for 15s.

SVT: typically caused by AVNRT; = Before taking adenosine, patients should be warned that they may experience= nausea, flushing, chest pain, or a sense of dread. Patients with bronchosp= astic lung disease should not receive adenosine.; AV nodal blockers (=CE=B2-blockers or calcium ch= annel blockers) are used to prevent recurrent AVNRT

- NSVT =3D = <30 seconds- vita= ls, pads,
- CBC, CMP, UA, UDS, TSH, Free T4, lactate, Trop
- EKG, CXR=
Consider: CT PE, DVT U/S, CTA Abd, Eho

acne
- no sca= rring: Tx with tetracycline
- scarring: Tx with oral isotretinoin (need = LFTs first)= ACS (= STEMI, NSTEMI, Unstable angina)
- score: HEART Score for Major C= ardiac Events - MDCalc for risk of major heart event, TIMI Risk Sc= ore for UA/NSTEMI - MDCalc for medical versus intervention (3+ sho= uld do intervention; 0-2 stress test), Pre-test = probability of CAD (CAD consortium) | QxMD for stress test (11-90%= should get stress test)

- STEMI: 0.1mV+ (if lead V2 or V3, 2+mm in = male over 40, or 1.4mm in female) OR new LBBB and biomarkers
- NSTEMI: 0= .5mv+ in 2 leads, elevated trop
- Unstable angina: ECG or Sx (not improv= ed with nitro), negative trop

Location
- V1-V2 =3D anteros= eptal (prox-mid LAD)
- V3-V4 =3D anterior (LAD)
- V5-V6= =3D apical (distal LAD, distal LCx)
- I, aVL =3D lateral (prox L= Cx)
- II, III, aVF=3D inferior (RCA, LCx) !!! if inferior M= I and bradycardic, give atropine first to increase HR. If you give NS= and HR is slow, will worsen pulmonary edema

- good for immediate ca= th - shock, severe LV dysfunction or signs/symptoms of HF, persistent or re= fractory angina, new MR

- nitroglycin gtt if pain after 3 sublin; no= nitro if sildenafil in past 24 hours (nitro decrease BP but re= flexes tachy)
- stress test if intermediate risk (
- can start lisino= pril 2.5mg

Heparin 60 U/kg IVB (max 4000 U); 12 U/kg/hr (max 1000 U= /hr initially), to aPTT (goal 50-75); pro: quick reversible by protamineEnoxaparin 1mg/kg SC BID for > 2d until patient stabilized. D/C if Plt = <100,000; pro: less likely HIT, but still can, not for renal issue GFR &= lt;30

- BP goal SBP < 140, keep DBP > 60 !!! no beta bl= ocker if LV failure with pulm edema or 2nd degree or 3rd degree heart block=

If= has chronic LBBB, need Sgarbossa Criteria (concordant depression >= 1mm in V1-V3 / concordant elevant >1mm in any contiguous leads / discord= ant ST elevation >5mm with negative QRS)

STEMI

- DAPT with ticagrelor 180 bolus then 90 BID for 12 mo= nths (better than plavix) and aspirin 81 forever

m= yocardial injury =3D trop with no symptoms, EKG, wall motion.

- stress testing: NPO 3 hours before, hold BB and nitrates.&nbs= p; Coronary CTA 99% negative predictive value for low risk patients

- if cardiac cath: hold medications that can harm kidney until after

Wellens' syndrome

- EKG findings only of de= eply inverted or biphasic T waves in V2-3, but no chest pain right now (may= have recent chest pain)
- need early/urgent coronary work up (Treated a= s unstable angina)

If RV infarct (h= ypotension after nitro and JVF with clear ynds, ET elevation on V4R : Tx: i= ncrease preload: Give IV fluids

- If VSD.papillary muscle rupture= after acute MI, need intraaortic balloon pump, sodium nitroprusside, and l= asix (decrease afterload) and emergent

<= div>- if beta bocker, nitrate, and dilt/verapamil still not helping with ch= ronic stable angina, can try adding on ranolazine (Ranexa)

!!! If ACS is stimulant drug induced, then BB can w= orsen coronary vasoconstriction; labetalol is preferred (b blocker with a b= locker)

- EKG, CXR
- admit to telemetry
- CBC, CMP, BNP
- serial= trop
- aspirin load 325mg, followed 81mg QD
- Keep O2 Sat > 92%, = supplemental O2 PRN
- heparin gtt
- *** metop tart 25mg q12h (to keep= HR 50-60) if no HF or severe asthma/COPD
- atorvastatin 40mg
- nitro= 0.4mg SL q5m PRN (max 3 dose within 15 min)
- morphine 2-4mg IV PRN for= severe pain, q15 min
- consider starting lisinopril if BP tolerates
= - TTE for new wall motion abnormality
- consult card
- no NSAID (incr= eases risk of cardiovascular event)

- start beta blocker metopro= lol/carvedilol unless contraindicated: advanced AV block, new HF, severe re= active airway (wheezing heard)acute adrenal crisis
- give fludrocorti= sone (mineralocorticoid) if still wobbly after hydrocortisone givenacute aortic regurg
-= SS: wide pulse pressure
- do not give beta blocker in acute aortic reur= g: will worsen
- Tx: if super low BP, dobutamine, sodium nitroprusside;&= nbsp;
- TX: ARB and nifedipine okay if patient has chronic aortic regurg= and HTN

(Beta blocker OK for Mitral STENOSIS and MVP

Mitral = regurg:
- surgical repair if EF < 60%

acute bleed on antiplt (aspirin, pla= vix, dipyridamole, prasugrel)
- if antiplt used within last 24 hours and= positive CT or surgery planned, or GCS < 14, 0.3mcg/kg desmopressin in = 50mL NS over 20 minutes AND transfuse 1-2 units of apheresis plts (=3D 6-12= packs of platlets)
acute chest syndrome
- most common by fat emboli
- criteria: p= ulmonary infiltrate on XR + increased work of breathing/cough/tachypnea/whe= ezing, 101.4F, hypoxemia, or chest pain
- Tx: ceftriaxone + azithro, IV = fluids, pain control
- common in sickle cell kidsacute encephalopathy, altered mental sta= tus (also see RRT - altered mental status & delirium)
- varicella, H= SV, syphillis, HIV, CMV, west nile, consider LP
- if meningitis, acyclov= ir, ampicillin

- If bacterial meningitis (likely strep pneumo or nei= sseria meningitidis); tx with ceftriaxone + vancomycin (van to cover penici= llin resistant strains of strep pneumo). If >50 yrs old, add ampic= illin, due to possible listeria meningitis.

-- Recommend meningitic dosing acyclovir 800 q8&nbs= p;

-- consider meningitic dosing ampicillin if clinica= lly concerned for meningitis

- cefepime has better= penetration

- 50+ or immunosuprresed, add ampicillin for listeri= a

- TB meningitis and fungal infection most common= cause of chronic meninigitis

- TB meningitis:

- Sx: CN 6 issues, low CSF glucose

- CT head with contrast= shows basilar meningea= l enhancement

- Tx: RIPE + dexamethasone if suspecting TB = meningitis + (vanc + cefepime)

#rule out meningitis: patient presents with ***headach= e, fever, nuchal rigidity, photophobia, maculopapular rash, cough, pharyngi= tis, n/v, myalgias. Differential includes viral meningitis vs bacterial.&nb= sp;

Viral meningitis most commonly from enteroviru= s (May till November), herpesvirus (HSV2 most commonly but also VZV, CMV, E= BV, HHV6-- year round) mosquito borne viruses (June till October)

Bacterial meningitis: most common S. Pneumo, then N m= eningitides serogroup B, then strep agalactiae. Consider listeria in older = adults and those with altered cell mediated immunity. Lyme disease unlikely= (patient meets rule of 7s -- headache duration <7 days. <70% CSF mon= onuclear cells, absence of a seventh facial nerve palsy) Less likely ddx in= cludes treponema pallidum (secondary or tertiary syphilis) and leptospiral = meningitis (uveitis, rash, conjunctival suffusion, lymphadenopathy, hepatos= plenomegaly absent)

Subacute (5+ days) or ch= ronic meningitis (30+ days)most commonly caused by TB and fungi. TB meningi= tis (SIADH, CN VI neuropathy), cryptococcus neoformans (suspect in AIDS, ne= utropenia, organ transplantation, advanced immune suppression), histo (acut= e respiratory symtpoms in setting of recent travel to Ohio, Missouri, India= na, Mississippi), coccidioides (acute or chronic pulmonary infection) =

- Lumbar puncture

- Se= nd for enterovirus PCR

- HSV2, VZV

- WNV IgM (PCR for WNV is insensitive)

-= Gram stain and culture

- LP x 3 days for gram sta= in and culture for TB -- can also send for AFB smear but this is often inse= nsitive. Would also perform NAAT.

- Urine culture of lepto= spiral meningitis

- Blood cultures

- Serum = cryptococcal antigen (positive in greater than 95% of infected patients)&nb= sp;

- Histoplasma urinary antigen assay (se, spe >85% in acute= and disseminated infection but less than 50% in chronic infection.) <= /div>

- Urinary antigen testing and serology for coccidioides immitis.&= nbsp;

- Dexamethasone (10 mg q 6 hours x 4 days) reduces morbi= dity/mortality in adults with pneumococcal meningitis, scheduled to given w= ith 1st dose of antibiotics. (discontinue if cause is not strep= pneumoniae; most comon bacterial meninigitis; otitis media or sinusitis as= symptom too)

Check reversible encephalopathy labs if not checked recently: Vitamin B1, Folate, B12, MMA, homocysteine, Vitamin D, Vitamin E, zinc, copper, ceruloplasmin, RPR, HIV, HTLV1/2, VLCFA, ESR, CRP, ANA

Acute HF heart failure (HFrE= F)
- criteria: EF <=3D40%
- Sx: S3 sound, lung crackle, JVD, BLE e= dema (Cardiac wheeze can happen vs COPD; steroids can increase = fluid retention)
- test: BNP
- cause: med compliance, toxin/meds, afi= b, ischemia/infarct, diet, hyperthyroidism, progression cKD, acute AKI, PE = or COPD worse R-side afterload), liver failure, thyroid, infection, sarcoid= ,
- wet and warm =3D diuresis, wet and cold =3D need CCU for inotr= ope and/or vasodilator
- hold ACE/ARB if hypotensive; switch to hydra or= nitrate if renal
- BB reduce 1/2 if moderate HF, d/c if severe HF (new = guidelines: continue if already started unless hypotensive)
- order iron= studies for all patients in acute exacerbation

- entresto also = good for HFpEF (PARAGON-HF trial)
- will need ischemic workup: stress te= st/CTA, angio
- GDMT:
- carvedilol or metop succ)
- = ARNI (if cannot take ARB, consider hydralazine-isosorbide dinitrate -= BiDil); if hx of angioedema, ARNI increases risk, so just do losartan
&= nbsp; - spirinolactone if GFR >30
- jardiance

ranol= azine for antianginal medical optimization vs. isodirl

ARNI can = drop blood pressure more; if already low BP, do losartan

minoxidil c= an lower diastolic BP

Stage B: structural heart disease, no symptoms= ; stage C: symptoms; stage D =3D refractory HF
NYHA =3D class 1 (no limi= tation), 2 (normal activity), 3 (minimal activity), class IV (rest)

= - avoid CCB, NSAID
- BNP can be falsely low in obese and HFpEF; high in = entresto

- get BNP and weight on discharge

BNP CAN BE f= alsely elevated in people with entresto

HFpEF
- GDMT: spirino= lactone (no mortality benefit) and jardiance

Indirect bili may be hi= gh in setting of congestive hepatopathy

- CRT if EF still < 35% a= nd LBBB with QRS >150ms after on GDMT

get a lactate for anyone who presents with decompensated HFrEF (usually like 2= 5% and less) WITH hypotension even to only the 90s - to catch early o= r ovious cardiogenic shock (cold and wet)

- imdur hydralazine for b= lack people with HFrEF for GDMT (will have little urine output)

=
: = BB, spirinolactone if Cr# Acute respiratory distress
# Acute on chronic = 2/2
Last LVEF: *** NYHA, ACC/AHA
- CXR
- CBC, CMP. TSH= , BNP, lipid, a1c, urine hCG, iron studies, HIV
- admit to telemetry
= - Lasix 2.5x home dose , net goal 2L
- KCL 20mg PO BID empirically
- = continuous pulse ox, keep O2 > 92%
- duoneb q4h PRN
- strict I/O- fluid restrict 1.5L
- standing weight
- TTE
- GDMT on discharg= e
- BNP and dry weight on discharge
- UDS

#Decompensated = HFrEF

EF ***% on bedside ultrasound. ACC/AHA Stage ***, NYHA Clas= s ***. Most likely etiologies include ***

#Troponi= n elevation: 54 to 71 over 1 hour on admission. Most likely completed infar= ct from several days prior to admission given clinical history.

- Rule out COVID as possible etiology of SOB

- NPO for= LHC in am

- Trend troponin with EKG

- Low = threshold for activating cath lab for LHC, particularly need for LV support= device (onset of chest pain, worsening hemodynamics and respiratory status= , EKG changes) .

- 40 mg IV lasix now

- ASA 325 m= g, then 81 daily

- High dose statin

- Hold or decrease = beta-blocker given decompensation at this time / Continue beta blocker give= n no signs of decreased perfusion (bisoprolol 10 mg daily, coreg 25 mg BID = (50 mg BID if >85kg), metop succinate 200 mg qdaily) / uptitrate beta bl= ocker over the next weeks for goal HR of 60.

- Hold p2Y12 f= or concern for possible multivessel and need for urgent bypass if needed

- f/u ECHO

- f/u TSH

- Lipid panel

- = Iron studies -- screen for iron df independent of Hb with repletion with IV= iron if Tsat<20% improves functional status (JACC 2008;14:103)

- HIV

- SPEP w/ FLC

- Avoid CCB&nbs= p;

- Salt restriction, fluid restriction

- Daily = weights

- Strict I/O

- If EF <40% = evaluate for valsartan-sacubitril initiating in outpatient setting once all= owed washout period of 36 hours, and check with Pharm/CM for prior authoriz= ation

- If EF< 35% add on spironolactone / eplerenone on= ce doses of ACEI and Beta blocker uptitrated to maximal levels, and Cr <= 2.5, K < 5.0

- If EF<35% -- consider ivabradine if HR >= 70/min despite maximally tolerated dose of beta blocker therapy

= - ICD indication -- iCM with EF<35% and 40 days s/p MI and NYHA Class II= /III

- CRT indication -- LVEF<35%, QRS > 150 ms, LBBB= , and sinus rhythm. .

- For African American (NYHA II= I/IV) -- add on isosorbide dinitrate hydralazine to other goal-directed med= ical therapy to reduce mortality.

acute pancreatitis
3xULN

BISAP Score for Pancreatitis Mortality

- cause: 1) alcohol, 2) = gallstone, 3) hypertriglyceridemia, vasculitis, cholesterol emboli, hypovoe= lmic shock, idiopathic, tumor, mumps virus, TB, toxo, autoimmune, scorpion = sting, drugs (lasix, thiazide, valproate, estrogen), high calcium
- 20cc= /kg IV bolus in 30 minutes then 3cc/kg/h NS or LR if dehydrated; else 5-10c= c/kg/hr.
- then switch to 1.5cc/kg (water fall trial) - 3cc/kg not bette= r - so 150cc/hr
- get CT with contrast if concern for nec pancreatitis
if triclyeride caused
- need insulin drip if triglyceride > 100= 0 (ICU), then start fenofibrate when <1000 (Dr. Cheng shares can s= tart right away). stop insulin gtt when <500
- D5LR 125cc/hr if gluco= se < 200, D10 if glucose < 140

- if any lesions, CT AP in = 3 months to reassess lesions and resolution of pancreatitis

complica= tions: most common is pancreatic pseudocyst (no matter the size, no drainag= e needed unless infected or symptoms)
- complication to watch out for: p= ancreatic necrosis:fever, leukocytosis. Need CT abd with con imaging and su= rgical eval if positive

- IF young adult with chronic pancreatitis, = do sweat chloride testing to rule out cystic fibrosis
- Chronic pancreat= itis: see calcium on CT pancreas protocol.

autoimmune pancreatitis- sausage shape pancrease with parenchymal swelling or narrowed pancreati= c duct (can mimic pancreatic cancer)
- Dx: test IgG4 level higher.=
- Tx: responds to steroid

- even if lipase normal, if possib= le panreatitis, contrast enhanced CT or MRI- lipase, lipid
- urine drug screen
- CT abd (= with contrast ideally)
- morphine
- Zofran PRN
- GI ppx: protonix = 40 IV BID
- diet: low residue, low fat, soft diet or clear liquid

#Acute pancreatitis: Patient with typical epigastric abdominal = pain radiating to the back, elevated lipase of {}, and typical abd CT findi= ngs. Most likely due to {alcoholic pancreatitis due to significant alcohol = history, gallstone pancreatitis}, although cannot exclude {alcoholic, galls= tones}, or elevated triglycerides causing pancreatitis. No signs of cholang= itis currently -- including fever, RUQ pain, jaundice, altered mental statu= s, or shock. ALT>3X ULN best predictor of gallstone pancreatitis with &g= t;95% PPV.

Classification:&nb= sp;

1. Mild acute pancreat= itis, which is characterized by the absence of organ failure and local or s= ystemic complications

2. Moderately severe acute p= ancreatitis, which is characterized by no organ failure or transient organ = failure (<48 hours) and/or local complications

= 3. Severe acute pancreatitis, which is characterized by persistent organ fa= ilure (>48 hours) that may involve one or multiple organs

4. Necrotizing acute pancreatitis- which is characterized = by inflammation associated with pancreatic parenchymal necrosis and/or peri= pancreatic necrosis.

- Consider: bi= liary stricture, Sjogrens, thyroiditis, IBD, nephritis, consider IGG4 and A= NA E -- defer for now given CT shows no typical findings of autoimmune panc= reatitis (classic appearance of the pancreas on abdominal CT in patients wi= th diffuse pancreatic involvement is sausage-shaped enlargement with homoge= neous attenuation, moderate enhancement, and the peripheral rim of a hypoat= tenuation =E2=80=9Chalo=E2=80=9D. In long-standing autoimmune pancreatitisi= nvolution of the pancreatic tail is almost always evident. Focal pancreatic= involvement is encountered more often in the head of the pancreas and typi= cally appears as a low-attenuation or an isoattenuation mass)

-GI= for EUS vs ERCP

- In patients with unexplained pancreatitis who = are at risk for underlying malignancy (age older than 40) and or worrisome = clinical features including weight loss and new onset of diabetes, CT with = pancreas protocol or magnetic resonance imaging (MRI) with magnetic resonan= ce cholangiopancreatography (MRCP) should be obtained.

-Gemfibroz= il 600 BID if hypertriglyceridemia

- NPO until patient with= out abdominal pain, then start with low residue, low fat, soft diet, if una= ble to eat in 2 days consider NG or NJ tube placement for enteral feeding

Enteral nutrition is recommended in patients with moderately sev= ere and severe acute pancreatitis who cannot tolerate oral feeding within 3= days. Consult nutrition service

- CBC, BMP, LFTs, albumin= , lipids, lactate.

- Bolus with LR 20 mL/kg of intravenous fluid = given over 30 minutes then LR at rate of 250 cc/hr x 48 hours {unless hyper= calcemic then use NS}

- Pain control with Dilaudid prn

= - Nausea control with Zofran prn

- RUQ US to assess for gallstone= s

- CBC/BMP Q8h to trend HCT and BUN, daily LFTs

- Cont= inuous pulse ox monitoring and supplemental oxygenation as needed

{- No need for abdominal CT at this time as pain is typical and lipase is = elevated 3x normal}

- Fasting lipid panel in AM to assess for hyp= etriglyceridemia {only if other sources not found}

- Strict I's/O= 's, if UOP <100cc/hr, additional fluid boluses as necessary

{-= If uncomplicated gallstone pancreatitis}Cholecystectomy prior to discharge= given gallstone pancreatitis

{- If gallstones complicated by asc= ending cholangitis} ERCP within 24 hours to presentation given findings of = acute cholangitis

{- If uncomplicated gallstone pancreatitis is t= he cause and not improving with worsening LFTs} GI consult for ERCP given g= allstone pancereatitis that is not improving and worsening LFTs

-= Antibiotics of {} given {} {only if cholangitis, cholecystitis, or o= ther intra-abdominal infections are present} -- CTX + flagyl or zosyn

- ESR, CRP

Afib / aflutter
- causes: recent surgery = stress, infection, MI, thyrtoxicosis, alcohol alcohol, PE, OSA, COPD, pneum= onia, CAD, abnormal heart valve (mitral regurg / rheumatic heart),stimulant= , caffeine, tobacco, electrolytes
- score: CHA= =E2=82=82DS=E2=82=82-VASc Score for Atrial Fibrillation Stroke Risk - MDCal= c (2+ for male, 3+ for female start anticoag, but some say 1+),&nb= sp;HAS-BLED Score for Major Bleeding Risk - MDCalc (3 =3D high= risk for bleed; does not cover for falls)
- paroxysmal: <=3D7 days, = persistent > 7 days, long-standing persistent >12 m, permanent =3D no= intervention

- metop careful in acute HF
- metop IV 5mg q= 10m PRN (max 3x, onset 5min), followed by PO 25mg q6h after HR <110, upt= itrate q6h by 12.5mg (can start 50mg BID if needed 10mg+), onset 4hr = (at the same time now too)
- dilt IV slightly more effective= rate control, shorter onset, and lower HR, but lower SBP (meta-analysis); = do not give in (systolic) HF
- dilt IV 0.25mg/kg i.e. 10mg-25mg&n= bsp;q10m PRN (x2, onset 2 min), then infusion 5mg/hr, up titrate 2.5mg q30m= in to max 15mg/hr.
- Add digoxin if dilt or BB doesn't work. no digoxin = if AMI, myocarditis, WPW, low Mg, low K, heart block.
- dig= oxin SE: nausea, confusion/hallucination, blurred vision

- if SBP 80= s, then
a) amio 150mg IV over 10 minute, (repeat x1 ok, gtt 1 hr= )
b) digoxin 0.5mg IV, follosed by 0.25mg IV q6h x2 (can do dig 1= .5mg total, i.e. 500mcg x3)

- if not stable (cool extre, altered, an= gina, pulm edema), sync cardioversion 150J (Afib needs 150J, Aflutter can w= ork with 50J) and increase if needed. Need anticoag at least 4 weeks after.= If need pressor, phenylephrine
Versed (midazolam) 2mg (+/-fent 50mcg)- warfarin if mitral stenosis, HOCM, or mechanical valve, rheumatic, else= can DOAC (Eliquis is BID)
- BB PO better than CCB at rate control
- goal on metop uptitrate <80 at rest and <100 when walking
Chad= vasc for nonvalvular afib only. 2+ start anticoag (okay to start 1+ i= n men) vavular =3D mod+ mitral stenosis, mechanical mitral valve: all= need warfarin (doac inferior)

- amio risk of stroke, works only whe= n up to 5g to 10g

- the only reason no need for DOAC for Afib = is if it's after CABG; do a Ziopatch and assess

Aflutter:<= br>- atrial rate 250-300 in 2:1 block, ventricular rate of 150

- if = starting amiodarone and on warfarin, decrease warfarin by 25% CYP2C9)
- do not give amio and dig one after another quickly as causes 3rd degree= av block (CYP2C9)
- amiodarone (what it dissolves in to infuse can caus= e hypotension, but amio itself does not cause hypotension)

= Patient should be monitored for amiodarone toxicity including the following: Annual EKG , TFT/LFT yearly), C= XR/PFT at baseline and then Q1Y ,

, yealy opthal exa= m , dermatological exam PRN

- Apica= l variant of hypertrophic cardiomyopathy -- cannot use CHADSVAsc score (nee= d to anticoagulatn)

# new onset Afib with RVR, likely 2/2 ***
CHADSVASc: ***, HAS-BLED:= ***
- EKG
- CBC, CMP, TSH, Free T4, BNP
- CXR
- TTE
- INR

#New onset atrial fibrillation

CHADSVASC *** likel= y precipitated by surgery, infection, MI, thyrotoxicosis, acute alcohol, PE=

First diagnosed // paroxysmal (within 7 day= s) // persistent (> 7 days), long-standing persistent (>12 months) //= permanent -- (stop further attempts to restore sinus rhythm)

- Outpatient study for OSA -- STOP BANG ***

- EKG

- Formal ECHO

- CXR

- CBC, CMP, TFT, BNP

- IV metoprolol 5 mg over 2 minutes,= repeat as needed q5 minutes x3

- PO metoprolol -- caution in dec= ompensated HF or severe bronchospasm

- Consider diltiazem 0= .25 mg/kg bolus over 2 minutes -- usually 10-20 mg

- PO dil= tiazem -- avoid in heart failure -- contraindicated in LV failure with pulm= onary congestion, LVEF <40%

Peri-st= able SBP

- Digoxin load 0.5 mg IV followed by 0.25 mg x 2 for loa= ding -- caution in renal impairment or accessory pathways -- long ter= m digoxin independenetly associated with increased mortality in AF patients= .

- Amiodarone 300 mg IV over 1 hour followed by gtt -- con= sider risk of pharmacologic cardioversion

- If pressors needed-co= nsider phenylephrine given reflex bradycardia

Cardioversion

- > 48 hours 2-5% risk of stroke ->= ; TEE to r/o thrombus or ensure anticoagulation > 3 weeks

- Long term anticoagulation -- Apixaban 5 mg BID = (2.5 mg if Cr > 1.5 AND age > 80 or wt < 60 )

Bridge with heparin or LMWH for CHADS Score >5

#first diagnosed atrial fibrillation: = CHADSVASC *** likely precipitated by surgery, infection, MI, thyrotoxicosis= , acute alcohol, PE

First diagnosed // parox= ysmal (within 7 days // persistent afib > 7 days, longstanding persisten= t afib >12 months // permanent -- stop further attempts to restore =

- Outpatient study for OSA -- STOP BANG *** =

- EKG

- Formal ECHO

- cxr <= /div>

- cbc, cmp, tftS,bnp

- IV metoprolol 20.5 - 10 mg= over 2 minutes, repeat as needced q 1-0-15 minutes

- PO me= toprolol -- caution in decompensated HF or severe bronchospasm

<= div>- Consider diltiazem 0.25 mg/kg bolus over 2 minutes -- usually 10-25 m= g

- PO diltiazem -- avoid in heart failure -- contraindicat= ed in LV failure with pulmonary congestion, LVEF <40%

<= div>

Peri-stable SBP

- Digoxin load 0.5 mg IVfollow= ed by 0.25 mg x 2 for loading -- caution in renal impairment or accessory p= athways -- long term digoxin independenetly associated with increased= mortality in AF patients.

- Amiodarone 150 IV over 10 minu= tes followed by gtt -- consider risk of pharmacologic cardioversion

- If pressors needed- consdier phenylephrine given reflex bradycardia&nb= sp;

- Long term anticoagulation -- 5 mg BID (2.5 m= g if Cr > 1.5 AND age > 80 or wt < 60 )

Bridge with heparin or LMWH for CHADS Score >5

AKI / CKD
- urine <50cc/hr for 6 hours,= 0.3+ increase in 48 hours, 1.5x Cr in 1 week
- GFR <20, no lovenox- cause:
- HUS, TTP, DIC concern
- urine eosinophil if concer= ned for AIN
- cause: kidney perfusion, glomerulonephritis, vasculi= tis, interstitial nephritis, thrombotic microangiopathy
- CK if rh= abdo
- BUN/Cr > 20 in prerenal
- monitor complications: cephalopat= hy, chest pain, fluid overload, pulmonary edema, HTN, platelet dysfunction<= br>- Stages: 1 =3D 90+
2 =3D 60+
3A =3D 45+
&nb= sp; 3B =3D 30+
4 =3D 15+

ESRD on dialysis with little urin= e - don't have to care about kidney, just do lasix 80 BID

- Obtain = PTH, Vit D level

- Target Phos 3.5 - 5.5 mg/dL, low phos in ESRD = is a poor prognostic marker

ESRD

- = Nephrovite and renal diet please, goal target protein intake of 1.2 g/kg/da= y for dialysis patient

- avoid PICC lines/limit access, ren= al panel and phos daily, daily weight please every am, Strict I/O, renal do= sing of all medications and antibiotics to current eGFR

-Titrate home meds, avoid hypotension, goal sbp>100, MAP>65

# Medication consideration for ESRD

= - Avoid sucralfate 2/2 aluminum toxicity

- Baclofen contrai= ndicated

- If MRI indicated, may proceed with MRI scan using grou= p 2 gadolinium agent (note that while currently no reported literature case= s of nephrogenic systemic fibrosis (NSF) from group 2 gadolinium agents, pt= should still be made aware of potential risks of developing NSF)

- Renally dose all medications with pharmacy

- Avoid morphine, n= orco, preferred opioids include hydromorphone

If fluid overload, lasix, then add metolazone 5mg tablet QD
= - diuril first before bumex/lasix to help increase diureses

if unequ= ivocal, then - serum uric acid: if uric acid < 4, then SIADH
bactrim = causes fake AKI (history lab measurement, but now doesn't --- if unsure, ca= n just check cystatin c) and can cause true AKI

To see chronic CKD, = can also test for PTH

starting dialysis - hepb, hep c, quantifer= on- Urine Urea, Na, = Cr
- UA for cast, protein, sediment
- CMP
- urine U/S r/o obstruct= ive
- strict I/O
- d/c nephrotocxic meds (ACEI/ARB, metformin, NSAID)=
- avoid nephrotoxic meds
- monitor complications, K, hypoNa, hyperPh= os, hyperMg

- Nephrovite and renal diet please, goal ta= rget protein intake of 1.2 g/kg/day for dialysis patient or lowering protei= n intake to 0.8 g/kg/day in adults with diabetes or without diabetes = and GFR <30 ml/min/ 1.73 m2

- avoid PICC lines/limit access, r= enal panel and phos daily, daily weight please every am, Strict I/O, renal = dosing of all medications and antibiotics to current eGFR

<= /div>

# Anemia

- target hgb 9-11 for ESRD, 10-12 for CKD, tra= nsfuse hgb <7

- Consider ESA if hgb is less than target hemogl= obin and no contraindications such as malignancy, uncontrolled hypertension= , or a history of stroke. No ESA if hgb > 11 g/dL.

- If TSAT &= lt; 30% and and ferritin is =E2=89=A4500 ng/mL, may consider IV iron sucros= e 100 mg administered during consecutive dialysis sessions for a total of 1= 0

sessions (1g). For CKD patients 200 mg administered on 5 = different occasions within a 14-day period. Avoid IV iron if active infecti= on.

# MBD

- Obtain PTH, Vit D level

- Phosphate binders as indicated

- Target Phos 3.5 - 5.5 = mg/dL, low phos in ESRD is a poor prognostic marker.

# Metabolic acidosis

- Can start NaBicarb tabs for CO2 < = 22 in CKD

- No need for Nabicarb PO in patients with ESRD on HD&n= bsp;

# HTN/Volume

-Titrate home meds, = avoid hypotension, goal sbp>100, MAP>65

# = Medication consideration for ESRD

- Avoid sucralfate 2/2 aluminum= toxicity

- Baclofen contraindicated

- If MRI ind= icated, may proceed with MRI scan using group 2 gadolinium agent (note that= while currently no reported literature cases of nephrogenic systemic fibro= sis (NSF) from group 2 gadolinium agents, pt should still be made aware of = potential risks of developing NSF)

- Renally dose all medications= with pharmacy

- Avoid morphine, norco, preferred opioids include= hydromorphone

- Avoid large BP flu= ctuations, goal SBP 120-140, avoiding nephrotoxic medications (eg contrast,= ACEI/ARBs), renally dosing medications

- Strict I&= Os. Daily weights. Avoid PICC lines. Renally dose meds.

#CKD: GFR of *** (Stage G1>90, G2 60-90, G3A 45-60, G3b 30-45= , G4 15-30, G5 <15)

Albuminuria stage A1 =3D mild 30 mg/= d; A2 moderate 30- 300 mg/d; A3 severe > 300 mg/d

UA wit= h positive protein -- check U prot: Cr to quantify because UA just checks a= lbuymin

Etiology of DM (44%), HTN/ nephrosclerosis (29%), c= ystic kidney disease (20%)

- If proteinuria -- goal is <= 500-10000 mg / d with RAAS blockade (ACE or ARB)

- BP control: go= al BP 130/80 ,f proteinuria, or SBP <120 if GFR 20-60 by MDRD

- If proteinuria with ACEI, then non dihydropyridiine CCB;

- If edema >> loop diuretic

- CVD risk reductio= n >> aspirin statin exercise smoking cessation

- Avoi= d nephrotoxins (bactrim, NSAIDS, lithium, acyclovir, contrast)

<= div>- Renally dose medications

- Nephrocaps; Na< 2gm/d, = fluid L <2L/day, k phos restriction,protein 0.6-0.8 gm/kg/d only if GFR = < 60 and nephrotic syndrome is not present

- U alb: Cr a= nd U prote: Cr, PTH, 25 vit D , CBC, FE studies

- Check ren= al US

- Urine/microalbumin: Cr ratio (mcg/mg =3D mg albumin= / day assuming 24 hr urine excretion)

- Nephrology referral= if GFR<30, severe albuminuria, glomerular hematuria, resistant HTN, met= abolic complications (hyperparathyroidism, anemia, acidosis, hyperkalemia, = hyperphosphatemia), unclear etiology of hereditary

- Check ca, PO= 4, 25 OH vita D (not 1,25 as level will fluctuate)

- Anemia= goal 10-11.5 -- iron repletion for goal transferrin sat >20%, hold if f= erritin >500-800

- Nephrology consult to consider Ea (contrain= dicated in cancer, HTN, HF)

- Metabolic acidosis: NaHCO3 65= 0-1300 mg BID For goal bicarb >22 shown to slow progression of CKD=

- Prep for HD access-- avoid BP measurement and venipuncture in = nondominant arm, avoid subclavian / PICC lines

Pre-Renal

Fluid challenge and = monitoring sCr over 24-48 hours
- Dx: urine lytes (urine sodium, urine creatinine, urine o= smolality, urine potassium), drawn prior to fluids if possible
- Tx= : Bolus until intravascular euvolemia. Consider lactated ringer=E2=80=99s, = sodium bicarbonate (150 mEq solution) if acidotic/NAGMA, or normal saline b= olus if hypo-chloremic and hypovolemic
  - Data for fluids subjective, although, consider bo= lus with mIVF if NPO or losing volume vs. boluses, then continue oral intak= e supplementation.
GFR should improve with vo= lume resuscitation
- By definition, pre-renal volume depletion should improve with fluids.=
Pre-renal vs. hypo-perfusion
- Cardiorenal: urine sodium may be below= 20, or low, and suggest decreased perfusion, however, does not indicate ne= ed for fluid administration, rather diuresis based on volume status and car= diac function
  - Dx: Volume status questions: BNP, peripheral edema, pulmonary vascular con= gestion, JVD
- Hypotension: patient may be volume deplete= d and hypotensive, leading to poor renal perfusion, however, if patient is = euvolemic after fluids have been administered, and patient continues to be = hypotensive, go through the algorithm of shock, consider cardiogenic, distr= ibutive, hemorrhagic, continued volume loss, and consider need for vasopres= sor support for adequate MAP for renal perfusion.

Intrinsic

Clinical feature: most common likely cause o= f intrinsic renal injury, in hospitalized patients, is likely acute tubular= necrosis (ATN). Renal recovery will behave with a pattern of rising Cr, de= creasing UOP, until eventually plateauing, followed by possible normal rena= l UOP vs post ATN diuresis. Once Cr is stabilized, UOP stabilized, often pa= tients may return to baseline Cr, slow progression to a new stage of CKD, o= r unclear.
Dx: urine studies as above work up, with urinalysis de= monstrating brown muddy casts.
- Most common cause of ATN: pigment induced, ethylene glyco= l calcium oxalate, carbon tetrachloride, indinavir, lead, mercury, tenofovi= r, vancomycin, ischemia (early vs late), decreased renal perfusion (hypoten= sion, cardiorenal, cirrhosis, sepsis with vasodilation), DIC.
DDx in this category often quite wider, and involves bucket for a mu= ch larger set of disease, involving, glomerulus, tubules, and interstitial = of the nephron.
Tx:
- diuretic use (loop diuretics for daily net even or= net negative depending on volume status)
- potassium binders for w= orsening hyperkalemia
- acidosis management depending on ventilatio= n dependence or oliguria/anuria
- fluid management depending on rec= overy phase post ATN diuresis
- Dialysis as below.

Post-= Renal

Dx: bladder scan, post void residu= al, and renal ultrasound
Tx: Placement of foley or relief of obst= ruction, with rapid improvement in sCr, hyperkalemia, azotemia
- consider post foley monit= oring for resolution of concomitant hydro-nephrosis, if not resolving, may = require percutaneous interventions with urology or interventional radiology=
  - Percutaneous= nephrostomy tube indications: obstructed kidneys with urosepsis, infection, or renal insuffi= ciency; non-obstructed&= nbsp;including urinary diversion for ureteral injury, fistula, cystitis&nbs= p;OR access= for intervention on tumors or stones

alcohol hepatitis
- alcohol use at least 2 months, = recent jaundice, AST/ALT >2 (AST < 500), INR >2, Bili > 3=
- score: Maddrey's Discriminant Function for Al= coholic Hepatitis - MDCalc for whether steroid or not

ITP (= immune)

- if plt <30k, give steroid dexamethsaone 40mg x4 days- if critical bleeding (to important anatomical space), platelet transfuse= + IVIG + steroid
- if severe bleeding, then IVIG or steroid

Alcohol withdrawal<= br>- DDx: metabolic, drug overdose, GI bleed, CNS infection, liver failure<= br>- if does not work with benzo, need ICU and benzo drip / phenobarb / pro= pofol (also seen versed/fent or precedex drip; everything exce= pt precedex drip needs intubation)
- if hx of withdrawal seizure or deli= rium tremens, prophylactic treat chlordiazepoxide 25-100 mg q6h x 24hrs, th= en 25-50 mg q6h x 2days
- CIWA <10 no meds needed; 9+ =3D mild, 16+ = =3D mod, >20 =3D severe
- VA: ativan 2mg PO q4h for CIWA > 10
<= br>- check vitamin K (lost in 7-10 days if pancreatic insufficiency/liver d= isease and ill / pancreatic insufficiency)
- Phosphatidylethanol to= test if drank last month

- thiamine 100mg IV (better than PO)= , 1mg folate daily, hypoK common.

Wernicke
- Sx: horizontal nysta= gmus, gait ataxia - from thiamine deficiency
- Tx: IV thiamine (500mg IV= q8h), then glucose

- PETH lab if not sure if patient drank

-= naltrexone not in liver disease or hepatitis or having opioids
- acampr= osate not in kidney disease
- else disulfiram =3D but causes vomiting/he= adache/flushing if drinks
!!! give thiamine before glucose

deliri= um tremens =3D hallucination, delirium, agitation fever, palpitations HTN

phenobarb - lasts 4 days (no benzo or porphrea) -- 5mg/kg up to 20mg/kg, can redose every 30 minutes (can double if not= working)

phenobarb - 10mg/kg (max of 900mg divided over 3 hour spli= t)

- if alcohol hepatitis, can do solumedrol 32mg daily (need GI= consult first) - steroid can cause confusion

- withdrawal on di= scharge (4-8): gabapentin taper (benzo sparing)

- gabapentin taper f= or

- clonidine for HTN in alcohol withdrawal;

- CIWA
- CBC, CMP, u= rine drug screen, UA with reflex
- IVF
- banana bag(Thiamine, folate,= multivitamin; thiamine first, then glucose)
- hold beta blocker due to = masking symptoms
- K, Mg, Phos, Glu
- fall, aspiration, seizure preca= ution
- NPO until AM to avoid aspiration

MInor withdrawa= l 6 - 48 hours, alcoholic hallucinosis 24 h - 6d, withdrawal seizure 6-48 h= , DTs 48 - 5d

- CMP, CBC, serum osm if HCO3&= lt;15 or AG

- CPK

- Utox

K,= Mag, Ca, PHos, Vitamin D

- IV thiamine = ;

-D5NS after thiamine to fix ketoacidosis

- REpl= ete lytes

- Folate 1mg daily

- MVI

- Use phenobarb if hx of DTs, seizures, BZD resistan= ce, success w/ phenobarb, or prior ICU admissions , current symptoms of DTs= , not responding to BZDS, >30 mg ativan equivalents , leaving AMA

<= div>

- PO ativan > IV ativan >> Valium and librium (= cleared by liver, ong half life, delayed toxicity)

- CIWA s= cale

- Consider switching to phenobarb if CIWA consistently= > 16

- Gabapentin 100 mg qHS

= alpha-1 antitrypsin
- tests: serum AAT (if <11mmol/L/<57mg/dL= and FEV1 <80%) can provide pooled human AAT augmentation to decrrease e= mphysema progression= ALS
- vital capcity can assess capacity
(NIF, PFT possible = too)amenorrhea- labs: T4, FSH and prolactinamyloidosis
- Sx: neuropathy, proteinuria, restrictive he= art (low volta ECG), periorbital echymosis (panda eyes)
- CMR (cardiac M= RI) imaging positive supports amyloidosis
- positive technetium pyrophos= phate scan =3D hereditary transthyretin amyloidosis
- abdominal fat pat = aspiration positive =3D AL amyloidosis
- Tx: beta blocker, diuretics if = edemaanal fissur= e
- Tx: sitz bath, psyllium; lidocaine topical
- if chronic (&g= t;8 weeks)with rectal spasm
- Tx: topical diltiazem/nifedpineanaphylaxis
- does not ne= ed SOB, hypotension qualifies (criteria: skin involvement + hypotension/res= piratory distress)anemia
- causes:
- MCV < 80: iron deficiency, chronic in= flammation, thalassemia and hemoglobinopathy, copper deficiency (rare), lea= d toxicity zinc toxicity, sideroblastic anemia (lead, alcohol, drugs). = ;
- MCV 80-100: acute, malignancy, bone marrow invasion or suppre= ssion, or primary disorder, cancer, CKD (low EPO), hemolysis, endocrine iss= ue (hyothyroidism, adrenal insufficiency)
- MCV >100: alcohol,= folate, vitamin B12, GI resection, vegan, liver disease, antiretroviral- if vita B12 low, need methylmalonic acid and homocysteine lab (if true B= 12 deficiency, both are increased. In folate deficiency, only increas= ed homocysteine).
- folate >4ng/ml =3D no deficiency. < 2ng/ml =3D= folate deficiency

- acute anemia: can also look at Calcium dropping= to determine dilutional vs
- iron sat <19% AND MCV low if ferr= itin is high, then mixed picture. If MCV normal, then only anemia of = chronic disease

for old people, iron deficiency anemia cancer un= less proven otherwise

- B12 deficiency: hypersegmented neutrophil,&n= bsp;
(will get higher LDH, indrect bili and AST =3D ineffective erythrop= oesis)

- zinc blocks copper absoprtion (i.e. good for wilson disease= )

iron deficiency:
- transferrin sat < 20%
&nbs= p;- ferritin < 30 ug/L
- ferritin 30-100 need serum tran= sferrin receptor/log ferritin >2
- ferritin > 100 rul= es out (=3D anemia of chronic disease)

for pregnant patients, us= e sucrose, NOT gluconate
There is a risk = of adverse maternal reactions (eg, anaphylaxis, hypotension, shock) followi= ng use of parenteral iron, which may result in fetal bradycardia, especiall= y during the second and third trimesters. An immediate hypersensitivity rea= ction has been reported in a pregnant patient (Cuciti 2005). Although the r= isk is rare, immediate treatment for anaphylactoid and/or hypersensitivity = reactions should be available (BSH [Pavord 2020]).

- reticulocyte count- peripheral blood smear
- TSH, free T4
- occult blood
- iron stu= dies if increased RDW
- B12, folate if increased RDW
- LDH (high),= haptoglobin (low - binds free Hgb), T bili (for indirect bili) if hemo= lysis
- Hgb electrophoresis if thalassemia/hemoglobinopathy
- abdomin= al U/S if spleen
- ESR, CRP if inflammation
- bone marrow biopsy if p= ancytopenia or abnormal cells peripheral blood

#acute on chroni= c anemia:

- Ganzoni Equation shows IV iron of ***

- f/u B12, folate, iron panel, ferritin

- CBC q 4 hours&nb= sp;

- IV pantoprazole

- Pediatric tubing for all = blood draws

animal bite
- augmentin most common
- ceftr= iaxone+flagyl (+vanc until MRSA negative)
- Need TDAP if <5 yearsankle
- test: ta= lar tilt test

high ankle sprain
- squeeze the calf =3D pain at hi= gh ankle
- Tx: ice for 20 minutes q2h, elevation, crutches/rest, elastic= wrapping to reduce swelling, and splint wotj ;eg brace to prevent ankle mo= vement, referral to ortho

- achielles rpture
- no plantar flexion= when calf squeezed

anklylosing spondylitis
- Sx: female < 45 yr old, mor= ning stiffness >30m, improvement with exercise, uveitis,
- Dx = of inflammatory sacroilitis: pelvic MRI for erosions or inflammatory at sac= roiliac joints

RA
- Dx: RF and anti-CCPanovulatory uterine bleeding
- irregul= ar heavy bleeding within 2 years after menopause without nausea or cramping=
- Tx: observation only - normal= anthrax
- Sx: flu-like syndrome then sepsis
- Dx: b= loody pleural effusion on CT/CXR and widening of mediastinumantiphospholipid antibody syndr= ome
- Sx: Angulated retiform purpura (sudden skin necrosis with jagged e= dges), pregnancy loss
- lupus anticoagulant, anticardiolipin Ab, anti be= ta-2 glycoprotein ab, measured 2x 12 weeks apart
- Tx: need warfarinaortic aneurysm (AA= ) (Thoracic or abdominal)
- risk factors: smoking, male, age, HLD, HTN, = obesity
- surgery M >5.5cm or >0.5cm/6months growth; female: >4= .5cm
- statin, BB, aspirin

- surveillenace: thoracic: if 3.5-4.4,= every year, more is 6 months
abdominal: <4cm is every 2 years; > = 4cm is at least every year

thoracic aortic aneurysm
- BP <140/= 90
- Tx: BB, ARB, statin
aortic dissection
- type A =3D surgical emergency, type B= =3D medical manage
- keep SBP < 120, HR < 60; IV labetalol. may n= eed nitroprusside (need betablocker with it else reflex tachy =3D worse) / = cardene drip
- !!! do not use hydralazine - increases shear stress
- = if d-dimer low (<0.5ug/ml), rules out aortic dissection
- Dx: CTA- D-dimer, trop
- CT = (higher sensitivity and specific than U/S)
- IV labetalolaortic disse= ction
BP < 120 with esmolol and labetalolaortic stenosis
- 50% mortality in 3 year= s if angina, 3 years if syncope, 2 years if HF/SOB
- aortic valve area &= lt;1cm and ( if mean AV gradient>40 OR ao peak velocity >4 =3D high f= low) then classic (classic high flow high gradient)
- o= nly pseudo severe should not get tavr. (Dobumatine stress increases ef to o= ver 50%)

- Heyde syndrome =3D angiodysplasia causing lower GI bleed<= /td>appetite stimula= nt
- progesterone, dronabinol, mirtazepine (may be preferred), megaceARDS
- Berlin cr= iteria: within 1 week of ARDS insut, bilateral opacities (pulmonary edema),= respiratory failure not due to HF, PaO2/FiO2 <300 when on PEEP 5+
- = mild: PaO2/FiO2 200-300, mod: 100-200, severe: <100
- Tx: 4-6cc/kg IB= W, pleateau (end inspiratory pressure) < 30, even if some acidosis and h= ypercapnia
- steroid NOT indicated in ARDS

O2 =3D FiO2 and PE= EP; pCO2 =3D RR and TV

ARDS: Mild (P:F ratio 200-300) Moderate (P:F ratio 100-200) Severe (= P:F ratio <100)

ACVC

- = Goal tidal volume of 6 cc/kg predicted body weight

- Goal r= ate 14-18

- FIO2 of 100% then reduce to 60% if SpO2 > 88= %

- PEEP of 10 given bilateral opacification of lungs on Xr= ay

- Goal SPO2 88-94% (PaO2 of 55-70)

- Pplateau = <30 --if above goal, reduce TV

- Ppeak < 45&nbs= p;

Pressure controlled

- PEEP 5-10= depending on degree of hypoxemia

- FIO2 of 100% then reduc= e to 60% if SpO2 > 88%

- Driving pressure (or inspirator= y pressure -- Pplateau - PEEP) of <15 cm H2O

- Rate of 1= 4-18 breaths per minute

- Inspiratory time to keep I:E rati= o 1:1.5 or higher

- pH of 7.15 / 7.25 or greater is a= cceptable given high risk of overextension

C= ompliance =3D Tidal Volume / Pplat-PEEP

6 P'= s of REfractory Hypoxemia :

Pee: consider diuresis

PEPP: Optimize PEEP

Paralysis: early paralysis within 48 = hrs of ARDS onset

Pulmonary vasodilators -- iNO trial to se= e if inhaled epoprostenol would be beneficial

Prone

Perfusion (ECMO) -- severe refractory hypoxemia if ventilated <7 days=

= aspergillus
- 45 degree branchingasthma exacerbation
- levalbuterol (Xopenex) to prev= ent tachy
- can also consider duoneb if severe exacerbation; can stack d= uoneb 3 time/hour if needed.
- can consider prednisone 40mg (methylpred = 32mg IV) daily for 5-7 days (better outcomes)
- IV MgSO4 2g if not re= sponding to intiial therapy

-if to ICU, need methylpred 125mg IB= q6h

outpt
- test: methacholine bronchial challenge - use only if= symptoms asthma but PFT normal (if FEV1 fall by 20% from baseline, t= hen positive)
FeNO (fractional exhaled nitric oxide) >50 ppb =3D eosi= nophilic airway and will respond to inhaled glucocorticoid; < 25 =3D unl= ikely to be eosinophilic airway and inhaled steroid won't work

DLCO = higher =3D condition that increase capillary blood volume (pulmonary alveol= ar hemorrhage, L to R shunt, asthma)
DLCO low when alveolar units destro= yed
COPD =3D low DLCO. asthma - normal DLCO

asthma - now symbicor= t PRN not albuterol. And step up symbicort. SMART therapy/

COPD/asthma =3D FEV1/FVC < 0.7
- (>12% in FEV1 or FVC) and 20= 0cc increase in baseline with bronchodilator =3D reversible airway obstruct= ion
both FEV1 and FVC decrease =3D restrictive lung disease
- normal = DLCO or high =3D asthma. low DLCO =3D COPD

heliox if patie= nt crumbs (helium oxygen)- SpO2 goal >92%
- albuterol neb 2.5mg/3ml q20m x3 dose then q2h= PRN
- avoid beta blocker

#asthma exacerbation: per patient = report has symptoms (cough, wheezing, chest tightness, SOB) that have a diu= rnal variation. 20** FEV1 documented as *** and shows variable expiratory a= irflow limitation (by increase of 12% in FEV1 or 200 mL or diurnal PEF vari= ability >10%). Patient's symptoms are not well controlled -- exhibits da= ytime symptoms >2x weekly and noctural symptoms >2x monthly in the la= st 4 weeks.

- Chronic cough as primary symptom concerning f= or coexisting GERD or UACS secondary to rhinitis

- Outpatie= nt eval for OSA as treatment of such improves outcomes

- We= ight loss recommendation on discharge to improve good response to standard = controller therapies

- Speech therapy referral given concer= n for vocal cord dysfunction

- Pulm referral as an outpatie= nt for evaluation of Bronchial thermoplasty (FEV1>60% but severe asthma = that is poorly controlled despite ICS/LABA combo therapy)

-= Oral glucocorticoids (typically 5 to 7 days of prednisone 40-50 mg)

<= div>- Administration of oxygen onto maintain oxytgen saturation > 93-95%=

- f/u sputum culture, CBC w/ diff, and IGE level -- if eos > = 3% in sputum, elevated eosinophils, elevated IGE refer to allergy/immunolog= y on discharge to discuss whether patient would be a candidate for antinter= leukin therapy (mepolizumab).

- Add on inhaled ipratropium = bromide w/ SABA q4-6 h standing x 24 hrs

- PCP follow up for Flu = PCV13, PPSV23

- Obtain PEF now for estimation of degree of contro= l (<80% personal best c/w poor control)

o =E2=99=80: 350-550 L/min, =E2=99=82: 450-750 L/min (RT= for baseline and can trend)

- If Impending resp failure d= uonebs, methylpred IV 125 mg, Mag IV 2g over 20 min, transfer to ICU <= /div>

- Consider Heliox for better laminar flow.

- On d= ischarge would discharge on low dose ICS-LABA such as symbicort for mainten= ance and PRN use given recent changes in mgmt per 2019 GINA Guidelines.&nbs= p;

azithromycin --- can help with inflammation; give also for COPD = patientsback pai= n
- local heat, massage, acupuncture, psinal manipulation
- NSAID if = above doesn't work, then tramadol or duloxeitine as 2nd line
- oxycodone= as 3rd line
- only if >6 weeks no improvement, then imaging (i= mmediate MRI if risk for spinal infection, cord compression, cauda equina)<= /td>

Differential dia= gnosis includes most likely musculoskeletal pain, muscle spasm/sprain, spin= al stenosis, sciatica.

Low suspicion for ver= tebral fracture, no point tenderness over the spine, falls, or recent traum= a, normal gait. Doubt spinal epidural abscess or hematoma. Patient has no s= ignificant risk factors for spinal epidural emergency such as fever, IVDU, = HIV, or anticoagulant use. No signs or symptoms concerning for cauda equina= syndrome - neurologically intact without any lower extremity weakness, sad= dle anesthesia, or incontinence. Doubt pyelonephritis or kidney stone, no f= evers, systemic symptoms, hematuria, or dysuria. Doubt AAA, no sig cardiac = risk factors, no pulsatile mass and normal lower extremity pulses.

= bactrim bad for AKI
atorvaquone if prednisone pulseBactrim SE: hyperKBehcet syndrome (oral ulcers, geni= tal ulcers) - a vasculitis issue
- 1st line =3D colchicine
- 2nd line= : apremilast (prevention of oral ulcers in Behet)bicitra more bicarb (30cc =3D 60meq) than= bicarb (24 meq)b= igemy
- start metoprololbilirubinemia very high, concern for cholangiocarcinoma

= - MRCP/MRI Abdomen WO/W contrast

- Obtain CA 19-9, CEA, and= AFP

- Please send hepatitis serologies (HAV Ab, HBsAg, HBsAb, HB= c Ab Total, HCV Ab, HEV Ab); ANA, Anti-smooth muscle Ab, Anti-mitochondrial= Ab. Iron including ferritin; Ceruloplasmin

- Start Lasix 4= 0 IV given moderate volume ascites

BiPAP, ACVC, chest PT
KUB NG tube= , OG tube

BIPAP
- increased work of breathing, hypoxemic with= pulmonary edema, and hypercarbic respiratory failure (or very sedate= d; opioid overdose --- anything to increase minute ventilation)

vent= ilator: 6-8;, 4-6 cc/kg IBW if ards, 8-9 if coming in for CO2 a= nd need to blow off. but increase rate for CO2 first (more bang= for buck)<= td spellcheck=3D"false" contenteditable=3D"true" class=3D"sorting_1">bloati= ng
- maalox (Mg Al OH)
- Tums (calcium carbonate)
- simethicone (f= orm big bubble and fart/burp)= BPH
- finasteride takes weeks to workbreast cancer prevention if risk is= >3%
- tamoxifen before menopause (increases risk of endometrial canc= er)
- tamoxifen and raloxifene after menopausebromocriptine useful after traumatic brain= injury to help recover, if not sure what to doBudd-chiari
- hepatic vein or IVC thrombo= sis
- Sx: RUQ pain, jandice, rapid ascites,bullous pemphigold
- non muocsa surfaces
pemphigus vulgaris
- involves oral and vaginal mucosa surface
<= br>porphyria cutanea tarda
- dorsum of hand and sun-exposed areas
BUN low - malnu= tritionBurn
- = goal: urine output 31-50cc/hr (titrate fluids to get this) for 24 hours
= - if burn > 25%, vitamin C 66mg/kg/hr x24 hours (no if Cr > 1.5, MI i= n last 6 months, hepatic failure, >8 hrs since burn
(UCI protocol ava= ilable)bypass- micronutritent deficiency - B1, B6, B9, 12, ACDEK iron, zinc, selenium, = copperc auris
= - Tx: micafungin= cabgf
- vein mapping (vascular lab), pft, carotid ultrasoundcalciphylaxis
- happens in= ESRD patients, painful ulcer
- cause: calcification in dermal arteriole= s
- Tx: no definitive treatment, but calcitonin and sodium thiosulfate (= anti-inflammatory)cancer

colon cancer
- programmed death receptor 1 inhibitors (P= D-1 inhibitors) for refractor metastatic colon cancer
- CEA q6m for 2 ye= ars and CT chest/abd/pelvis yearly for 5 years

breast cancer
= - Her2 positive Tx: trastuzumab, need echo q3m
- peau d'orange - need co= re needle biopsy
- inverted nipple + erythematous at some portion of bre= ast =3D inflammatory breast cance r(3% of all breast cancers)

cervic= al cancer
- stage 1/2:: hysterectomy and pelvic node dissection
- sta= ge 3 (extension to pelvic sidewall, lower third of vagina, or pelvic adenop= athy): cisplatin + radiation

neuroendocrine tumor
- if no symptom= s even if metastasis to liver, observe with interval 3m imaging. If s= ymptoms (face flushing /diarrhea), somatostatin analogue

colon adeno= carcinoma
Tx: fluorouracil and oxaliplatin

non-small cell lung ca= ncer with ALK translocation
- Tx: alectinib
non-small cell lung cance= r with no mutations or programmed death ligand expression, Tx with combo ch= emo (carboplatin and pemetrexed) + pembrolizumab
- if have PD-L1 express= ion, then can just use pembrolizumab

ALL, CLL, AML low Hgb and Plt

CML high WBC. Tx: imatinib

ALL and CLL large spleen, lymph nodes.

APML Tx with retinoic acid.

High risk AML, need stem cell transplant after chemo; If = low risk AML, after complete remission, then do "consolidation chemo" - as = some cancer cells still can't be seen.

chronic lymphocytic leu= kemia: high mature lymphocyte (>5) and smudge cells
- test: flow cyto= metry
- Tx: IVIG if low IgG or low IGA and having infections

non-= hogkin lymphoma - large B cell lymphoma
- stage with LDH (internat= ional prognostic index score)

brain mets with elevated ICP
- = high dose steroid to reduce tumor vasogenic edema

Pdl1 score - wheth= er benefit from immunotherapy

P16+ scc =3D HPV associated
If high= risk - remove, chemo (cisplatin) and radiate

Thyroid cancer: test f= or BRAF gene - =3D papillary carcinoma =3D aggressive form of cancer
in = melanoma, also look for BRAF

cardiogenic shock
- criteria: SBP < 90 for 30m or = pressors needed + cold extremities/oliguria/lactic (hypoperfusion) + hemody= namics (CI < 2.2, PCWP > 15)
- test: EKG, troponin, TTE to exclusi= on tamponade
- cause: MI, ESRD< myocarditis
- goal: CO > 4, CI = > 2.1, mixed venous >65 (dobutamine) initial dose 0.5-1mcg/kg/m= in; or milrinone (also inodilator) 0.125mcg/kg/min

if severe hypoten= sion, use epi, levoped

= cardioversion
- need 3 weeks of anticoag before CV (or TE= E echo) and 4 weeks after carpel tunnel
- weakness and numbness 1st 3 fingers, wors= e at night
- Tx: decompression if have muscle weakness/atrophy; if= no evidence of weakness, then neutral wrist splinting at night and = steroid injection (can aso do short course oral steroid)

lateral= epicondylitis (tennis elbow)
- too much wrist extension
- Sx: pain a= t lateral elbow, radiates down back of hand, worse at night and with activi= ty
- test: pain at elbow with forced extension of wristcauda equina
- bilateral leg w= eakness, saddle anesthesia, bowel/bladder dysfunction
- PE: absense dist= al reflex and leg weakness
- caused: disk herniation, spondylosis, traum= a, infection, cancer (prostate, lumphoma, multiple myeloma)
- = ;dexamethasone and emergent MRI
- surgery consultcdiff
- last thing can trial IV= IG if severe (can be considered to fight infection)

#C. Diff colitis: atypical presen= tation given patient does not endorse watery diarrhea, but definitely +RF g= iven IBD. C. Diff PCR positive on 05/06/20. Non-severe (WBC<15, and Cr &= lt;1.5) Severe (WBC > 15, Cr > 1.5) Fulminant

- PO va= nc 125 mg q 8 hours (05/07/20 - 5/17/20)

- Probiotics daily= -- shown to decrease recurrence compared to placebo >50% with no signif= icant adverse effects (Gastro 2017; 152: 1889)

- Isolation precau= tions

Cdiff: use fidaxomicin in CKD patients = instead of vancomycin or in severe
Fulminant cdiff (systemic toxicity): = po vanc, iv Flagyl and rectal vanc<= /tr>celiac
- anti-ttg IgA and IgGceliac
- Sx: failure to thrive, chroni= c diarrhea, has dermatitis herpetiformis (elbow, knees rash) low fat-solubl= e vitamins, iron deficiency anemia, elevated LFTs
- test: TTG tissue tra= nsglutaminase; (tissue transglutaminase IgA) when patient is eating gluten = (cannot test accurately if not eating gluten) --- if has IgA de= ficiency, need to test IgG anti-TTG or IgG gliadin.. Also need small = bowel biopsy if test result is positive
- genetic testing: HLA-DQ2 or HL= A-DQ8 can rule out, but cannot confirm
- Dx: any positive celiac disease= pt needs bone mineral density testing

cellulitis / skin infection
- lab= s: trend CRP/ESR
- can use MRSA nares for r/o MRSA 95% specificity (mod = sensitive only)
- scoring: LRINEC Score for Necrot= izing Soft Tissue Infection - MDCalc for nec fasc
- Tx: vanc un= til MRSA nares (nares specific, but not sensitive)
- Tx duration: uncomp= licated 5 days, purulent 10 days

purulent =3D typically MSSA and MRS= A
- Tx: oral Bactrim 2 tabs BID, clindamycin 300mg PO q8h, or doxycyline= 100mg PO BID
- IV: vanc

nonpurulent =3D staph or strep- tx: cefazolin 1g IV q8h, ampicillin-sulbactam (Unasyn) 3g IV q6h. if pen= icillin allergy, clinda 600mg IV q8h
- tx duration: 5-7 days

= clostridium perfringens nec fasc
- Tx: penicillin + clindamycin

e= mpiric for necrotizing fasciitis =3D vancomycin/dapto/linezolid + zosyn + c= lindamycin, carbapenem, ceftriaxone+metronidazole, or cipro+metronidazolecrepitus =3D clostridium, no crepitus =3D group A strep

(clinda fo= r toxin), vanc + zosyn kills kidney; better vanc + cefepime+flagyl
IDSA 2014 guidelines to use: mild mod severe

ESR male age/2, fe= male age+10/2 is normal

- 7 to 14 days'

- doxy (<- for MRS= A) + augmentin as unasyn coverage oral

bactrim has poor coverage for= strepchemothera= py desensitizationDay 0 (night prior to desensitization):

-HOLD PATIENT'S = HOME ACE-INHIBITOR

-Patient is admitted to ICU. Labs are drawn.&n= bsp;

-Dexamethasone 20 mg IV X 1

-Cetirizine 20 m= g PO x1

-Montelukast 10 mg PO x1

-Famotidine 40 m= g IV x1

PRE-MEDICATIONS ONE HOUR PRIOR TO = STARTING (ON THE MORNING OF):

-HOLD PATIENT'S HOME ACE-INHIBITOR<= /div>

-Dexamethasone 20 mg IV X 1

-Zofran 8 mg IV x1&nb= sp;

-Cetirizine 20 mg PO x1

-Montelukast 10 mg PO= x1

-Famotidine 40 mg IV x1

MEDI= CATIONS 4 HOURS AFTER MORNING PRE-MEDICATIONS:

-Cetirizine = 20mg PO x1

-Dexamethasone 20 mg IV x1

= ;

P.R.N. medications:

Cetirizine 20 mg PO q4 hour= s PRN for flushing / itching / rash

Famotidine 20 IV q8 hou= rs PRN for GI symptoms

Zofran 8 mg IV q6h PRN for GI sympto= ms

Benadryl 25mg PO q2 hours PRN or flushing / itching

= Albuterol 0.83% nebulized solution inhaled q2 hours PRN shortness of breath= / wheezing.

EPINEPHRINE (1:1000) (1mg/ml) IM drawn at beds= ide in 1cc syringes x3 with volume of 0.3ml in each with 22 gauge 1" needle= s ready for IM injection as needed for anaphylaxis.

<= div>Proceed with DESENSITIZATION after informed consent for desensitization= is signed.

Chest pain
- Causes: - pericarditis (diffuse upslope ST elevation)
- NSTEMI, = STEMI, PE (new RBBB, S1Q3T3, RV stain), aortic dissection
- anxie= ty, GI (e.g. biliary colic)

chest pain cardiac stress test good for = 5 years;
- look cad CAD consortium score
- inpatient lexi= scan good for 1 year

typical: with stress, nitro, substernal , atypi= cal 2 of 3, non cardia =3D 1 or 2 or these.

now called "cardiac, possibly cardiac, or noncardiac" - nitro doesn't = really tell (helps with HF as well)

-CXR, CT PE, Echo

Differentia= l includes ACS, pneumonia, COVID-19, pneumothorax, pericarditis, musculoske= letal chest pain. Doubt pulmonary embolism, no hypoxia or tachycardia, and = lack of significant VTE risk factors. Doubt aortic dissection.

chest tube vs thoracentesis:
- if loculation, then chest = tube as can put in tpA and flush
- chest tube to suction or gravity
-= thoracentesis: upper limit 1.5L can take out (can cause reexpansion = pulmonary edema if more); versus take out until cough or pain (lung is expa= nding)

chest tube < 200cc/day, (water seal) then can take che= st tube out

if constant bubbles in water sesal when off wall suction= , bronchpulmonary fistula or and air leak in chest tubechickenpox:
- S&S starts on f= ace and trunjk, then goes to extremities. progresses over hours to vasicles= with pusCholedo= chol - >7mm on ultrasound. Add 1 for every 10 years over 60. = ;Straight to ercp if bili>4 and cbd dilated

Pancreatitis 10cc/kg = bolus and then 1.5cc/kg/hrchorea gravidarum
- rare disease when newly pregnant female sud= dently has random non-repetitive, flowing dance-like movement that cannot b= e supressed.
- test: pregnancy test

vs. huntington is slow progre= ssive condition (mood and cognition would be first) then chorea
vs wilson disease - involuntary movement with tremors
- test: serum ce= ruloplasmin or 24-hr urine copperchronic hypoxia and air travel safety/high altitude
- o= xygen sat curve steep part if baseline oxygen sat is already low if going t= o high altitudes
- pts with SpO2 > 95% okay
- 92-95% need high alt= itude stimulation testing
- <92% at baseline, need 2L/min supplementa= l oxygen prescribed (no additional testing)cirrhosis
- order factor 8 if not know why thr= ombocytopenia; if increased, due to liver (cytokine causes increase in fact= or 8)
- normal factor 8
- high factor 8 level also can cause bl= ood clots

acute hepatic encephalopathy
- causes: bleeding= , infection, dehydration, medication non-compliancecirrhosis
- score: prognosis: Child-Pugh Score for Cirrhosis Mortality - MDCalc ; if alcoho= lic hepatitis; if severe (PT and T Bili has an index score 32+), steroids f= or 28 days; MELD score; MD= F score for steroid
- U/S with and without doppler. Nodular =3D cirrhros= is (also low plt)
https://www.mdcalc.com/calc/3081/nafld-non-alcoholic-f= atty-liver-disease-fibrosis-score
- outpt Fibroscan (ultrasound)
- fu= rosemide, decrease salt <2g,
- tips if Para every other day
= Terlipressin+ albumin: need liver and renal on board for pulmonary edemaUses carvedilol over propranolol/nafolol as 4x more effective in reducing = varices
Omeprazole is for post banding healing
No octreotide if just = gi bleeding and does not have liver disease

- all patients with cirr= hosis should get EGD to assess if any varices
- only if mod/severe varic= es, start =CE=B2-blocker (propanolol, nadolol, carvedilol)

- check v= itamin K

- furoesmide: 40: spirinolactone: 100 (if need al= bumin to chase with lasix, albumin 25% 25gm BID)

- if hepatorena= l syndrome - trial octreotide and give albumin (if low BP, midrodrine too)<= br>
- if any surgery for cirrhosis patients: post-op risk is using VOCAL= -PENN risk assessment score

- ultrasound every 6 months for surveill= ence on HCC if someone has cirrhosis

!!! if alcoholic hepatitis,=
prednisolone for MAddrey discrimnant score >=3D32, MELD > 20, or = encephalopathy (If bili does not improve or Lille score does not impr= ove in day 7), stop prednisolone.
- do not use steroid if also have GI B= leed, infection, pancreatitis, or CKD

- hold ACE inhibitors, ARB= < NSAID with patients with ascites
- if variceal bleeding, octreotide= + CTX

hepatorenal syndrome:
-

-Etiology: due to HC= V

-Diagnosis: based on

-HE:

-Ascites:&n= bsp;

-EV screen:

-HCC screen:

-Immuniza= tions:

-Check Hepatitis C Ab

-Chec= k Hep B serologies (Hep B S Ab, Hep B S Ag, Hep B core Ab)

-Check= HIV

-Check iron studies including ferritin and transferrin

-Check ceruloplasmin

-Check ANA, antimitochondrial antibody = (AMA), anti-smooth muscle antibody (SMA), IgG, (Anti-LKM Ab)

-Che= ck alpha-1-antitrypsin

-AFP

-Ultrasound with Doppler

-INR

#Cirrhosis decompensated by (as= cites/ hepatic encephalopathy / jaundice/ variceal hemorrhage) secondary to= ***ALD/NAFLD

- MELD-Na ***, MELD ***, CP***

-HCV genot= ype ***, treatment naive ***. Completed treatment on *** with SVR 24***

-Diagnosis: based on***.

-Etiology: Likely due= to ***

-Ascites: Current regimen ***. SBP prophylaxis (yes/no)**= *

-HE: Today, Pt has ***mild asterixis without confusion.&n= bsp; Continue lactulose ***mg and rifaximin ***mg

-EV: EGD (***) = showed with ***bands placed. Repeat EGD planned for ***. Currently on= Coreg 3.125mg BID.

-HCC Screen: AFP wnl (***). Last ultras= ound (***)

-Elastography (***) showed *** kPa consistent with sta= ge *** fibrosis.

-Coagulopathy: Plt ***, INR ***

-Immun= izations: HAV immune (***); HBV ***immune, series completed (***), Prevnar = (***), Pneumovax (***), Tdap (***)

-***Pt is not currently a cand= idate for liver transplant due to other comorbid conditions

<= /div>

- Volume:

- Spirono= lactone 100 mg / lasix 40 mg

- Na restriction <= 2g/d

- Fluid restriction <1.5 L (given Na <1= 25)

- Paracentesis in the am

- Avoid ACE/ARB (causes decreased renal perfusion)

-= Consider midodrine 7.5 mg TIPS for refractory hypotension

- Given concern for hepatorenal syndrome -- will start albumin and= octreotide and midodrine.

- Infection

- Send cultures for SBP evaluation (PMN>250)

- C= eftriaxone 2g q 24 hours x 5 days

- 25% albumin (1= .5 g/kg on day 1 and 1 g / kg on day 3 given Cr > 1 / BUN> 30/ Tbili = > 4)

- Discontinue beta blockers given increased mo= rtality in those with SBP

- Prophylaxis indicated = given prior SBP or low total protein in ascitic fluid (<1.5) WITH hypona= tremia, kidney dysfunction, or CTP class B or C

- Bl= eeding:

- Outpatient GI referral for EGD to evaluate for = esophageal varices

- Non selective beta blockers f= or prophylaxis

= High concern for current bleed -- s= tart PPI, GI referral, octreotide drip

- Encephalopa= thy

- Lactulose with titration of 3 BM/day or improvmeent= of metnal status

- Can add on rifaximin if refrac= tory

- f/u Zinc -- if deficient, add zinc 220 PO d= aily to help augment urea cycle and reduce ammonia.

- Screening / Surgery

= - PCP follow up to ensure adequate vaccinations

- Co= unsel to avoid the use of alcohol, opiates and benzodiazepines (which can p= recipiate hepatic encephalopathy), raw shellfish.

- Recommend out= patient screening of osteoporosis as cholestasis results in decreased absor= ption of vitamin D

- Protein consumption essential to preve= nt catabolic effects of chronic liver disease -- daily protein intake of 1.= 5 g/kg body weight recommended

- Avoid NSAIDS

- MELD > 15, refer to liver transplantation

- Liver c= linic f/u for HCC screening q 6 months

- RUQUS now and AFP level&= nbsp;

#Cirrhosis probably 2/2 ALD

MDF of 35. MELD of 21. Though patient's MDF>32, prednisolone fo= r ALD would be contraindicated at this time given concern for active infect= ion at this time -- though patient has been placed on a short course of pre= dnisone 40 mg 10/04/20 - 10/9/20. Given patient's Crohn's disease, some con= cern for PSC-- though less likely given normal alk phos and previous MRE sh= owing no PSC. Patient's elevated t bili and d. Bili may also indicate some = concern for cholestatic injury ( R ratio of 0.7)

- F/U on dedicat= ed liver ultrasound to evaluate for e/o portal hypertension and liver lesio= ns

- Chronic liver disease work up:

Viral hepatit= is work up has been negative (Hep A, HBCAB IGM, Hep C, HBsAg all nonreactiv= e). ANCA negative, ANA negative, C3, WNL, C4 low/normal, RF negative, cerul= oplasmin negative.

Pending A1AT, but given patient's age an= d history of alcohol use, A1AT deficiency unlikely cause of his cirrhosis.&= nbsp;

- Continue to monitor

- If pt worsens and his lun= g disease is not infectious in origin can consider referral for transplant = evaluation. At this time he is stable and we are not sure etiology of his h= emoptysis, would be premature to refer for transplant evaluation.

# Possible HE - covert

- Continue lactulo= se - titrate to 3-4 large loose BM per day

- If not controlled wo= uld consider adding rifaximin

# Possible ascites= and fluid overload

- Diuresis per primary team

- If as= cites on ultrasound please perform dx paracentesis (send fluid for cell cou= nt, diff, gram stain culture, albumin, total protein, AFB, ADA)

-= Low sodium diet <2000 mg per day

- Continue to monitor <= /div>

cocaine
- Sx: HTN, A= MI-like
- Tx: lorazepam
- Tx: Ca channel blocker for chest pain
- = Tx: phentolamine (a1 blocker) for HTN
- do NOT give betablocker, will ca= use unopposed a1 vasoconstriction
- cocaine risks dissection of aorta, w= ill see more platelets, and risk of thrombus
colon cancer screening
- 1-2 sessile s= errated polyp < 10mm without dysplasia =3D 5-10 years
- 3-4 polyp =3D= 3-5 years
- 4+ =3D 3 years
- <20 <10mm hyperplasti= c polyp also 10 yearscolorectal cancer
- prevention: baby aspirin helps if fam hx. Start = Colo 45/50 to 75 q10y, cologuard q3y, FIT/FOBT q1y. FOBT false positive if = meat eater. If immediate family hx, then start at 40 or 10 years before dia= gnosiscoma physi= cal exam NIHSS (template)

NEUROLOGIC EXAM:

Mental status: Lethargic/comatos= e/obtunded/stuporous/opens eyes spontaneously to voice. No response to voca= l or painful stimuli.

Language: Intubated, not follow= ing commands.

CRANIAL NERVES:&= nbsp;

CrN II: PERRL, blinks to threat bilaterally.

CrN III/IV/VI: Oculocephalic reflex intact bilaterally. Does not track ex= aminer=E2=80=99s face.

CrN V: Corneal reflex present bilate= rally. Blinks spontaneously.

CrN VII: Symmetric facia= l grimace to noxious stimuli. No obvious facial asymmetry. Unable to = assess for facial symmetry due to patient being intubated.

CrN VIII: Unable to assess.

CrN IX/X: Gag refle= x present.

CrN XI: Unable to assess.

CrN XII: Unable to assess.

Motor: No spontaneous movements. No withdrawal to painful stimuli. Tripl= e flexion reflex present in LE. Decorticate (flexed)/cerebrate (extended) p= osturing in response to noxious stimuli. Unable to assess strength due to m= ental status. Able to lift all 4 extremities antigravity.

R= eflexes: 2+ triceps, biceps, brachioradialis, patellar, achilles. Toes down= going/mute/upgoing bilaterally.

Sensory: Unable to assess.&= nbsp;

Fine coordination: Unable to assess.

Gait: = Unable to assess.

constipation
- activity, psyellium, then add d= ocusate (surfactant), osmotic laxative (MagOH, lactulose, sorbitol, PEG - p= eg is best), then senna (Stimulant laxative). IF all does ot work, th= en lubiprostone and linaclotideconstrictive pericarditis
- signs: circumferential perica= rdial calcification on XR of heart or >3mm pericardial thickeningcontrast
score: = Mehran Score for Post-PCI Contrast Nephropathy - MDCalc- NS pre and post procedure for 6-12 hours if any AKI or GFR < 30. Not= needed if GFR 45+
- some thought of mucomyst helping prevent contrast i= nduced nephropathy, but research not clear

contrast
- MRI gad= olinium not causes contrast nephropathy; NSF nephrogenic systemic fibrosis = rare but also need creatinine GFR30

COPD exacerbation
- Tests: COVID/flu, BNP= ; + sputum culture if risk factor; ABG if acute hypercapnia suspected (high= HCO3, or severe airflow obstruction FEV1 <50%
- Tx (inpt):
= - (controversial; some only start if sputum, purulence, or needing O2) cef= triaxone for 5(-7) days; cefepime/zoyn if risk of pseudomonas (prior, sever= e COPD, bronchiectasis, broad antibiotic use in past 3 months, chronic oral= steroid use); alternatively, amoxicillin, TMP-SMX, doxy
- <= br> - BIBAP to blow off CO2
- duoneb iptratropium-albuterol= 0.5-2.5mg q1h for 2-3 dose, then q2-4h PRN
- prednisone 40mg equ= ivalence for 5 days (up to 14 okay) (equivalent to methylpred IV 32mg= ); if severe COPD, methylpred 60mgq6h
- DVT ppx

: ICS= -LABA-LAMA triple therapy (trelegy or breztri contain all 3)

&nbs= p;Or ICS-LABA + LAMA. Ics-laba choices are symbicort, advair, dulera, breo,= wixela, breyna. Lama c= hoices are incruse or spiriva.

- consider azithromycin ppx to prevent COPD exacerbations (MKSAP)
if on= budesonide, do 1mg BID neb

- duoneb q4h PRN
- prednisone 40mg 5 days
- flu, pneum= onia immunization
- procal if infection suspected
- Bcx
- smoking = cessation

# COPD Excerebration GOLD Grade 1 (FEV > 80%, 50-8= 0, 30-50, <30) Group A / B / C / D COPD: Patient's FEV1/FVC <0.70 in = 20** PFTs.

- Trigger: ***

- ABG shows: ***

<= div>- Chest X-ray shows: ***

- Respiratory Panel ordered, will tr= eat influenza if detected

- Sputum culture and gram stain

- Legionella urine

- *** {Levofloxacin or Moxiflox= acin or Ceftriaxone or Cefotaxime} for hospital exacerbation without concer= n for pseudomonas

- *** {Cefepime vs Ceftazidime vs Zosyn} = if risk factors for pseudomonas: *** {Previous colonization, FEV <30%, B= ronchiectasis, broad-spectrum antibiotic within 3 months, chronic glucocort= icoid use}

- Prednisone 40 mg x 5 days

- NIV if change in mental status, pH < 7.35, or paCO2> 45

- Fan therapy can help decrease sense of dyspnea (nursing communica= tion placed)

- Duonebs q 4 hours standing, q2hrs pRN

<= div>- Continue Long Acting Bronchodilators as soon as possible (GOLD 2020)&= nbsp;

- On discharge would initiate LAMA given GOLD C exacerbatio= n history (Spiriva, Incruse ellipta)

- If eosinophilia (>300) = would initiate ICS+ LABA (advair, dulera, symbicort), though caution in arr= hythmia or CHF with LABA use.

- Would avoid advair if fre= quent admissions for pneumonia.

- Evaluate for home = O2 if PaO2 < 55% OR SaO2 <88% OR cor pulmonale / HF/ erythrocytosis (= Hct>55%) and PaO2 < 55-60, O2 <89%

- Pulmonary rehabilit= ation referral placed given *** FEV 1 < 50%, on systemic steroids, or re= cently hospitalized

- PCP follow up for flu vaccin= e and pneumococcal vaccination

- PCP follow up for Lu= ng Ca Screening: Annual low dose CT (55-80 with 30 pack yr hx and active us= e or quit <15 yrs

- For smoking cessation=

Varenciline is superior to nicotine replacement therapy and bu= proprion (Avoid in kidney disease and neuropsychiatric issues)

= Nicotine patches should be given at night to reduce AM cravings = ;

Buproprion is beneficial for concurrent weight gain, b= ut cannot be used in those with seizure disorder.

COPD
- Sx: symptoms slowly progress, history of smoking, = trigger
- PE: wheezing, tachypnea
- score: mMRC dyspnea scale (SOB sl= ight uphill =3D 1 vs. stop for breathing/after 100 yards/few minutes =3D 2+= or COPD assessment test (CAT)
- Dx criteria:
- FEV1/FVC <= 0.7 required for Dxthpe
- GOLD now ABE
- FEV1 80= %+ =3D1 (mild), 50+ =3D2 (mod), 30+ =3D3 (severe), <30 =3D 4 (very sever= e)
- mMRC 0-1 or CAT <10 =3D A/E (/old C); mmRC 2+ or C= AT 10+ =3D B/E(/old D). 2 COPD exacebation or 1 leading to hospital =3D E (= old C/D), else A/B
- Risk factors for poor outcome in acute exacerbation= : 65+, HF/ischemic heart disease, severe COPD, 2+ exacerbation, hospitaliza= tion for exacerbation last 3 months, supplemental O2)
- Tx (outpt): GOLD= A =3D albuterol PRN, B =3D LABA+LAMA, E =3D B and add ICS if eosinophil is= 300+ (used to be B =3D LABA/LAMA, C LAMA) + pulmonary rehab
= ; - ICS don't use if repeated pneumonia, hx of mycobacteria, eos <100, b= ut ok to add if 1+ exacerbation before
- LABA+LAMA better than LA= BA + ICS (before, if fail would go to LABA+LAMA)
- Aerobika can h= elp mucus clearance, decrease COPD exacerbation
- exacerbation ou= tpt: prednisone 40mg 5-14 days
- Rx:
- tiotropium (Spiriva) = =3D LAMA
- Wixela =3D fluticasone + salmeterol (LABA)
-= dry powder only if patient can deep inhale

- measure AAT level in p= atients with COPD

- for severe COPD, can do roflumilast to preve= nt recurrent exacerbations (cannot use when exacerbation)

- pu= lmonary rehab first.
- chest PT only if sputum
- if refractory SOB, u= se handheld fan (devices that increase airflow), pursed lip breathing (inha= le through nose, exhale mouth)

- lung volume reduction therapy -= upper lobe predominal emphysema, FEV1 and DLCO of 20% or higher and low ex= ercise tolerance.Inhalers: Respiratory = Medication Chart (lung.org)

coronary art= ery disease
- pretest likelihood

Coronary calcium ct has good sen= sitivity. 2 or less rules out.

No lexiscan for reactive lung disease=

#stable angina = pectoris: 2 months of stable reproducible anginal symptoms

= - Continue aspirin (clopidogrel if intolerant)

- Continue s= tatin

- Continue ace/arb

- Continue beta blocker = with titration to 55-60 (B1 selective B blockers such as metoprolol if sign= ificant lung disease)

- Consider*** CCB or nitrates

- Consider ranolazine

#coronary rev= ascularization:

- NPO for CABG evaluation (diabetes hx, LV = dysfunction, left main, three vessel disease)

- After revascularization: aspirin forever

DAPT =3D Clopidogrel= + aspirin

BMS =3D 1 mo DAPT minimum

DES = =3D 6 months (can continue if high risk for thrombosis -- depressed LV func= tion, saphenous vein graft stenting, diabetes)

CABG: DAPT 1= 2 months (improve patency of vein grafts)

coug= h
- DDx: asthma, heart failure, GERD, allergic rhinitis, post-nasal drip= syndrome, upper airway cough syndrome, ACEI, cancer, TB, bronchietasis, IL= D, idiopathic, cystic fibrosis
- acute cough due to bronchitis: reassura= nce (dexomethrophan doesn't really help; should avoid in SSRI pt, can incre= ase it); Acute bronchitis is a self-limited inflammation of the bronch= i due to upper airway infection, typically caused by a viral pathogen; it i= s typically associated with a cough that lasts from 2 to 3 weeks, mild dysp= nea, and sputum production. No CXR needed; CXR only if fev= er, tachypnea, tachycardia, rales, or signs of parenchymal consolidation
- unexplained cough: gabapentin can dampen neural sensitization for un= explained chronic cough.

- post infectious cough: normal for 3-8 wee= ks after infection common viral or mycoplasma (atypical)
- dry cough: fl= onase -> spirometry -> exclude eosinophilic bronchitis (with sputum e= osinophil analysis) -> trial GERD PPI
-of productive cough, worse at = night but not allergic: 1st gen antihistamine (benadryl) + decogestant (pse= udoephredrine)<= td spellcheck=3D"false" contenteditable=3D"true">CO= VID
- Sx: fever, chills, cough, SOB, fatigue, muscle ache, headache, los= s taste smell, sore throat, congestion/runny nose, nausea, vomiting, diarrh= ea
- no paxlovid if on statin (can stop statin)
- paxlovid or molnupi= ravir if mild to moderate

- classification: mild =3D no SOB, b= ut other symptoms, moderate =3D evidence of lower respiratory disease clini= cally or imaging SpO2 94+%, severe =3D <94% or PaO2/FiO2<300mmHg, RR&= gt;30, or lung infiltrate >50%; critical =3D respiratory failure, shock<= br>
remdesivir:
- mild to moderate with risk to severe (3 day course= if non-COVID diagnosis and incidentally COVID+)
- onset <=3D7= days and either: >60, HTN, stroke/CAD, DM, BMI 30+, immunocompromised, = GFR<60, cancer, chronic liver or lung disease, sickle cell, CF, dementia= , smoking, TB
- remdesivir 200mg IVP x1, 100mg IVP day 2 and 3- severe COVID - SpO2 <=3D94%
- remdesivir 200mg IVP x1, 100m= g IVP day 2-4

Paxlovid
if GFR 60+ =3D nirmatrelvir 300mg (2 tab)= + ritonavir 100mg (1 tab) q12h x5 days
30-60 =3D nirmatrelvir 150 mg +&= nbsp; ritonavir 100mg

paxlovid interactions meds: ranolaz= ine, amio, dofetilide, flecanide, placix, rivaroxavan, ticagrelor, cabamaze= pine, colchicine, rifampin, st. john's wort, lovastatin, simvastatin, silde= nalfil, midazolam

If hypoxic, add on dexamethasone 6mg daily
= - and daily d-dimer ,CRP, LDH, troponin, ferritin, CBC w/ diff q48 hrs (sev= erity labs)
- decadron 6mg

Tocilizumab:
for patients with high= oxygen needs with COVID

#COVID positive: Typical course for COVID will start with Dyspnea = at 6 days post exposure. COVID Severity Labs: ESR ***, CRP ***, Procalciton= in ***, LDH ***, Prothrombin Time ***, D-Dimer ***, Fibrinogen ***, Ferriti= n ***, Interleukin 6 ***, Troponin I ***.

Risk fac= tors: Age >65, HTN on medication, DM on treatment, COPD on treatment, hi= story of asthma, CAD on treatment, ESRD, obesity BMI >30, absolute lymph= ocytes <0.8, ferritin > 800, D-dimer >1000, CRP > 10, bil= ateral viral PNA on CXR. Patients with TSH, lipid, A1c, Vit D abnormalities= are at higher risk

{inpatient admission for= severe dyspnea, oxygen sat of <90% on RA, signs of end organ damage}

#Acute Hypoxic Respiratory Failure

#SIRS P= ositive based on *** {suspected infection + tachycardia, leukocytosis, RR, = + organ damage =3D sepsis, + pressors =3D Septic Shock}

#CO= VID Infection: Prediction for ICU Admission or Ventilatory Support: ***% (S= ource: http://covidrisk.hs.uci.edu/, modeled from 87 patients)

- = Satting ***% on ***

- Admit to tele

- Started on = Remdesivir (GFR >30) (**) for 5 days and Dexamethasone 6mg {any oxygen} = (***) for 10 days

- Consider Paxlovid or Xevudy if available vs t= ocilizumab or baricitinib (mortality benefit), will talk to pharmacy <= /div>

- Consider Lasix spot dosing if increasing oxygen requirements wi= th goal of -500ml to -1L

- Symptomatic Control: Benzonatate PRN, = Guanifenesin PRN, Tylenol PRN, Melatonin qHS, inhalers q4hrs, Chest Physiot= herapy QID

- Empiric antibiotics for pneumonia if suspected= (low threshold)-- azithromycin (x 5 days) plus ceftriaxone (MRSA nares***)= , discontinue ceftriaxone in 48 hours if no evidence of bacterial infection= .

- Blood cultures, lactate, Sputum gram stain and culture,= Urine legionella, LFTs

- COVID severity labs q48 hou= rs

- Contact and droplet precautions; encourage incentive s= pirometry, encourage proning

- Low threshhold for intubatio= n in setting of rising oxygen requirement

- Target O2 satur= ation of 92-96%

- DVT prophylaxis and continue unless platelets &= lt; 30 given procoagulable form of DIC despite low platelet count in COVID = patients

CPK myositis
- statin induced, hypoth= yroidism (delayed deep tendon reflex), or polymyositis/dermatomyositis
<= /td>crazy paving = =3D most likely due to PAP vs pulmonary alveolar proteinosis
NSIP -= Nonspecific interstitial pneumonia (pleura sparing)crohn's: high likely for pyoderma gangre= nosum
- infliximab (anti-TNF anti tumor necrosis factor= ) + azathioprine (immunomodulator)
- steroid to treat f= lares (budesonide)

- sulfasalazine only good for colon part (i.e. mo= re in UC)

8 years after crohn or IBD diagnosis, need colonoscopy, th= en every 2 years-Please order iron panel, ferritin, zinc, copper, vitamin a, e, d, vitamin= b12, folate, Mg, Phos, and replete as appropriate

-Ensure = DVT prophylaxis as IBD patients are at increased risk for venous thromboemb= olism

cryptococcus
- If immunocompromised p= atient has lung cryptococcus infection or disseminated cryptoccus infection= , need LP even if no CNS symptoms. From lungs, it commonly goes to CN= S.cryptogenic org= anizing pneumonia (BOOP)
- diffuse ILD that does not respond to differen= t antibiotics
- Sx: persistent nonproductive cough and flu-like
- Dx:= high resolution CT, PFT
- assoc with history of dematomyositis/polymyos= itis
- DDx: eosinophilic pneumonia, CAP, hypersensitivy pneumonitis
-= Tx: steroidcryp= togenic pneumonia (COP) - if antibiotics doesn't resolve in a few weeks.CT head protocol- any minor head injury if 65+, coagulopathy, drug or alcohol usedcushing
- S&S: pu= rple striae, diabetes, HTN, round face
- Dx: late-night salivary cortiso= l, serum ACTH, 1mg overnight dexamethasone suppression (should decrease cor= tisol to <3ug/dl - false positive for alcohol use obesity or psych issue= s)
- if morning ACTH high, pituitary MRI, if morning ACTH low or normal,= adrenal CT.= cysti= c fibrosis
- XR: lung has "tram tracks", pairs of parallel linear opacit= ies, hyperinflation of chest, bronchiectasis
- S&S: recurrent lung i= nfections, sinusitis, chronic productive cough, diarrheaDalbavancin

daptomycin: doesn't work for = group b strep, risk of rhabdo, need CPK baseline
delirium:
- DDx: benzo, narcotic, al= cohol, SSRI, anti-Ach, digoxin, muscle relaxant, low oxygen, high PCO2, inf= ection, stool, seizure, head trauma, poor PO intake, metabolic, sleep distu= rbance
- leading causes of delirium are fluid and electroly= te disturbances, infection (most commonly urinary tract and pneumonia), met= abolic disturbances, sensory/environmental disturbances, and drug toxicity.= The top three classes of drugs most commonly implicated in precipitating d= elirium are opioids, benzodiazepines, and drugs with anticholinergic proper= tie
- normally hyperactive, hypoactive or mixed; agitated or lethargic, = slow, incohrent speech, attention impaired, disorganized thinking, abnormal= sleep cycle (vs. dementia: normal, difficulty finding words, attention not= impaired, disoreitned, normal sleep cycle)
- old people: haldol better = (if IV, need cardiac monitoring), olanzapine okay

To treat delirium<= br>1st line: olanzapine (Zyprexa) - 2.5mg PO daily (max 10mg/day) &nb= sp;<-- zy
risperidone 0.25mg PO BID (max 1.5mg.day)
Seroquel (quet= iapine) - 25mg PO BID (max 400mg/day)
Abilify 5mg PO (max 15mg/day)
-= !!!seroquel first line if any concern for Parkinson as all others will set= their motor skills back a month even with a dose

Acute psychosi= s:
- olanzapine 2.5mg IM (max 10mg/day)
- haldol IM (not IV, IV gets = torsade) 0.125mg IM q6h

severe agitation
- "B52": benadryl 50mg, = haldol 5mg, ativan 2mg
- first haldol, then add ativan

anxiet= y: atarax hydroxyzine (causes confusion)
- seroquel for agitation
- g= eneralized anxiety=3D CBT first; SSRI. benzo short term while titrating SSR= I okay.

-= meds reviewed
- bowel regimen
- UA with UCx, ABG, urine drug screen<= br>- CT head if no delirium causes found
- Keep LP, EEG in mind
- d/c= antichlorinergics, benzos, zolpidem
- pain management

Delirium

- Maintain day/night orientation with appropriate ambient lighting a= nd re-orient patient frequently as needed

- Provide adequate day = time stimulation such as presence of family, verbal interaction with nurse = or visitors, or TV or music, and at night, minimize stimulation from vitals= , labs, or noise

- Avoid anticholinergic medications such as Bena= dryl and benzodiazepines, which will exacerbate confusion

- Start= scheduled {Risperdal, Haldol, Zyprexa, Zydis, Seroquel} {0.25 , 0.5 , 2.5,= 12.5} mg {PO , SL} q5PM x 3 days

- Start additional PRN {same dr= ug/dose as above} nightly at 21:00 as needed for agitation

- Star= t Trazodone {50, 100} mg nightly PRN insomnia.

- 1:1 sitter or re= mote observation

#Altered ment= al status: Ddx includes metabolic, infectious, drugs vs medications, primar= y CNS, delirium.

Patient's acute AMS concern= ing for trauma vs vascular vs increased ICP, meds/toxins, metabolic. <= /div>

- EKG to evaluate for arrhythmia

- UTox for possi= ble substance abuse

- AM cortisol, TSH

- Bl= adder scan for urine retention

- Seizure, stroke, syncope&n= bsp;

- CBC, BMP, LFT, lactate, NH3, B12, TSH, VBG,= UA, CXR, bladder scan

- ESR, CRP, CK, B12, B12

-= TTP consideration (low platelets, anemia, renal failure, fever, neuro chan= ges) -- LDH, stat smear

- Elevated T,HR,BP,RR concerning fo= r serotin syndrome >> neuroleptic malignant syndrome

- Consider EEG

- Consider MRI w/ gad for possible = stroke vs malignnancy

- Consider LP

- HIV, = RPR, HSV, VZV,

- Delirium mprecautions

= dental work Abx (amoxicillin or clindamycin; "clindamycin is anerobe above = diaphragm")
- only if
- prosthetic cardiac valve or repair with prost= hetic material
- Hx of infective endocarditis
- cyanotic congenital h= eart disease
- cardiac transplantdepression
- if dementia/strokem, use citalopram (SS= RI)
- sertraline safe to patients with heart disease
- mirtazapine se= dates and causes weight gain (Good for patients having wt loss and insomnia= )
- can trial weaning antidepressants if in remission after 6 months (do= n't stop abruptly); if recurrence, then take medication for duration of how= long the gap between episodes was

- do not take tramadol and = SSRI together (serotonin syndrome)<= /tr>dermderm steroid cream

topical steroid SE: atrophy, hypopigmentati= on, atrophy.

each "finger tip unit" =3D 500mg - treats 2% BSA (si= ze of palm =3D 1% body surface area);

30g tube covers entir= e body once=3D

= dermatology

dermatitis herpetiformis
- autoimmune bull= ose disease - clustered vesicles/bullae but very itch, so when you see it i= n clinic, they've scratched it and just red scars. At knees (elbows, = butt, scalp)derm= atology

verruca plana (flat warts) =3D "flesh-colored, papules= " face and legs of kids/young adults, less keratin than "verruca vulgaris" = (comon wart)
- Tx: topical salicylic acid, cryo, imiquimod

seborr= heic dermatitis (greasy scales) =3D selenium sulfide

tinea ver= sicolor (disolored dots on skin by malassezia)
- topical ketoconazole, terbinafine, clotrimazole, or selenium sulfide

chronic= spontaneous urticaria
- round plaque suddently, no trigger, goes away i= n 24 hours.
- Tx: claritin
- 50% won't have episodes after 5 years- no skin biopsy unless fever, or if last 24+ hours

lichen planus- polygonal shape at flexing surfaces or white lines in mouth
- Dx: sk= in biopsy
- if positive, test for HepC (associated)

increased risk for melanoma: 2 1^st degree with hx, 100+ moles, r= ed hair
skin: epidermis (keratinocytes in spinosum layer), dermis (fibroblast (makes connective tissue protein for wound healing/scarring), collagen, elast= ic fiber, oil glandss), subcutis/hypodermis (fat)
filaggrin =3D protein in epidermis, keeps in water; mustation causes atopic derm= atitis
erythema nodosum - inflammation of subcutis
sezary syndrome =3D body surface >80%; skin turnover causes metabolic issu= es, renal filtration and cardiac output issues.

color, shape, secondary feature, texture, size, palpability (mention whether well demarcated)

dermatom= yositis
- Sx: rough cracked hands like mechanic hands, gottron papules, = raynauds, arthritis
- Dx: anti-Jo, ck, aldolase. Need Mri of most painfu= l. Biopsy of skin/muscle possibly, myomaker
- rheum attending says= if confirmed whole body ct w contrast/pet scan (also for polymyositis)
= - steroid and methotrexate; cellcept for skin, azathro is for ski. And musc= le
- associated with ILD , need pft if SOB

CREST
- no skin= rashes
- Dx: anti-centromere

immune-mediated necrotizing myopath= y
- sx: acute muscle weakness and sob
- statin (would alsobhave= hmgcr ab positive), CK extremely high >10k
- Dx: anti-SRP (signal re= cognition particle)

rapidly progessive necrotizing myositis
- ant= i-HMG-Coa Ab (from statin)diabetes insipidus
- Dx: calcium to rule out high Ca as cause = for polyuria
- Dx: water deprivation. then desmopressin response t= o see if central vs nephrogenic DI. IF desmopressin challenge is posi= tive, order MRI. if negative, order kidney U/Sdiabetes
- type 1 diabetes melli= tus, one or more autoantibodies directed at the following targets are typic= ally present: GAD, tyrosine phosphatases IA-2 and IA-2=CE=B2, islet cells, = insulin, and zinc transporter 8
- 1st order GAD (glutamic ac= id decarboxylase) antibody testing is negative, it should be followed by ty= rosine phosphatase IA-2 and/or zinc transporter 8 testing

diabetic n= europathy
- use gabapentin/lyrica, duloxetine to treat; 8% capsaicin pat= ch if feet also.

#diabetes: A1C of *** (date)

Consider metformin on discharg= e given benefits in weight loss, lipid improvement, prediabetic <60 and = obese. Avoid if ongoing diarrhea. Contraindications include severe renal dy= sfunction (eGFR <30 mL/minute/1.73 m2); acute or chronic metabolic acido= sis with or without coma (including diabetic ketoacidosis). Counsel that th= ere is a tachyphylaxis effect and that this will minimize with time and wit= h food.

- Evaluate for B12 df

- lactic acid=

Consider GLP-1 on discharge as it reduces C= KD progression and provides ASCVD benefit and helps with weight loss. Avoid= if medullary thyroid cancer, hx of pancreatitis, or gallbladder / biliary = disease (preferred if A1C >9%)

Consider SGLT2 i= nhibitors on discharge as it decreases heart failure hospitalization, nephr= opathy, and helps with weight loss. Do not initiate in AKI, contraindicated= in those with GFR <40-45, those with history of candida infections, or = fournier's gangrene. Avoid canagliflozin in diabetics with PAD given increa= se in amputations. Avoid dapgliflozin in those with bladder cancer.

- Diabetic educator

- Home diabetic= supplies (order placed)

- Given new onset diabetes and A1C= of <8% will initiate Metformin / >9% (or after 3 mo of metformin) wi= ll initiate dual therapy ( metformin + Insulin/oral) / if still uncon= trolled=E2=80=A6. Triple therapy (metformin + GLP-1 receptor agonist + insu= lin) / >10% =3D insulin (or glucose of 300 or higher)

- Consider pramlintide (amylin analogue) as adjunctive therapy= for T1DM

- Given concern for T1DM: screen with GAD 65, Zin= c, and IA-2 autoantibodies

diabetes:- ketosis prone diabetes= Dialysis line
- Microbacterial (endocarditis), staph, and= fungal cannot do salvage therapy for tunneleddiarrhea
- labs if fever, IBD, food handle= r/healthcare, >70 yrs, heart disease, >6 stools/day, severe abd pain:= Bcx, Cdiff,PCR testing, HIV if young, parasite/ova ; feca= l calprotectin, fecal elastase (pancreas)
- Tx: if fever and doing bad, = can do azithromycin or fluoroquinolone
- STEC/EHEC, don't treat with ant= ibiotics due to shiga-like toxin
- Shigella: can actually treat
- Tx:= can give loperamide and bismuth (loperamide slightly better) if too much&n= bsp; (but don't give loperamide if fever or blood in stool - can incr= ease chance of toxic megacolon in cdiff)

- azithromycin/cipro for ET= EC diarrhea

- juice (high in fructose) worsens viral gastroenteritis= because GI not absorb fructose =3D causes osmotic diarrhea; instead give e= lectrolyte fluid hydration oral hydration and small amount of glucose (hypo= -osmolar); just eat normal diet - limit sugar and fat

- can calculat= e osmotic gap 290- 2(stoolNa + stoolK)
- <50 =3D secretory =3D= infection (GI electrolyte transport messed up, lots of Na and K in stool)<= br> - >125 =3D osmotic (stomach not absorbing stuff)

giardi= asis
- Sx: oily stool, from dirty water
- double nuclei
- Tx: tini= dazole

C diff
- vancomycin 125mg QID PO for 10 days for sev= ere (alb <3 and (WBC > 15k or abd tender) ; fidaxomicin if not = responding to vanc
- metronidazole PO 500 TID for mild-mod - complicated =3D If very severe, vanc 500mg QID + IV flagyl 500 q6h.
=

SIBO - small intestinal bacterial overgrowth. Blo= ating, lots of farting, and chronic watery diarrhea. Just GI bacteria= overgrowth. Dx with carbohydrate breath test (if hydrogen high, then =3D b= acteria fermenting). Tx: oral antibiotic rifaximin/ciprofloxacin for gram-n= egative GI organisms and diet modification. Folate will be high and v= itamin B12 will be low.

chronic diarrha:
= - seretory diarrhea =3D large volume watery, also night time, unchanged by = fasting (290-2NaK) if > 100 =3D osmotic, if < 50 =3D secretory<= br>osmotic: not nocturnal, most likely lactase deficiency. happens wi= th eating.
- Dx: colonscopy and biopsy for microscopic colitis (co= mmon in women 45-60, with nocturnal diarrhea; stop NSAID, PPI)
- h= igh fecal calprotein for IBD, urine stool laxative sreen, low fecal elastas= e level for chronic pancreatitis, fecal fat for steatorrhea (celiac SIBO, s= hort bowel, pancreatic insufficiency), stool gap (stool Na, K)

<= br>microscopic colitis:
- age 45-60 women:
- stop NSAID, SSRI, PPI- Dx: colonoscopy biopsy is normal
Tx with loperamide, bismuth for dia= rrhea. budesonide to help also.

#acute on chronic diarrhea: <4 weeks in durati= on. Likely infectious though could be early fungal infection as well. Likel= y small bowel etiology given watery, large volume, with cramping / bloating= // large bowel given small volume, painful, fever, and blood, and mucus. E= xposure includes travel, antibiotics, recent hospitalization, food, sick co= ntacts, day care, immunocompromise. Most often viral etiology -- norovirus = (less likely given not wintertime) vs rotavirus vs adenovirus. Could be bac= terial, though often severe, but cannot rule out in setting of immunocompro= mise -- E. Coli, campylobacter, salmonella, shigella, C. Diff. Parastici in= cludes giardia, cryptosporidia, cyclospora, e. Histolytics. In immunocompro= mised will evaluate for CMV, C. Diff, cryptosporidia, isospora, microsporid= ium, MAC, TB, histo, and cryptococcus

- Defer antibiotics given p= atient is not febrile -- if develops sepsis or signs of inflammatory diarrh= ea can consider fluoroquinolone vs azithromycin

Avoid loper= amide for infectious causes, can use pepto as alternative

-= Blood cultures

- Stool culture

- C. Diff&n= bsp;

- CMV

- Beta D glucan

- Biof= ire GI

If chronic -- work up for secretory, = osmotic, functional, malabsorptive, and inflammatory in etiology.

- CBC, BMP, ESR, CRP

- TSH,

- Stool lytes = (Na, K pH)

- Fecal WBC, calprotectin, fecal fat, lactoferrin, FOB= T.

- 290 - 2 X (Na + K) --

- If >50-- evalua= te for lactose intolerance, sorbitol, antacids, medication, celiac, S= IBO

- stool pH < 6 consider carbohydrate malabsorpti= on

- If <50 -- evaluate for secretory etiologi= es: infectious, non-osmotic laxative, microscopic colitis, alcoholism, hype= rthyroidism, bile salt malabsorption, medication

- If feca= l fat positive consider malabsorption such as Celiac or maldigestion (chron= ic pancreatitis, SIBO, cirrhosis)

- Consider celiac disea= se in setting of weight loss and abdominal pain

- = IgA, IgA anti ttG, HLADQ2, IgA endomysial

- I= f inflammatory -- consider IBD, ischemia, infection, radiation, or neoplasm= .

-------= ---------------------------

Exposures: Food Hx (ra= w, undercooked meat/fish), residence, occupational exposure, travel, pets/a= nmials, hobbies, recent abx

Characteristics: duration (acute <= 3 wks), frequency, fever, blood, mucus, abdominal pain, bloating/gas/= dyspepsia, relationship to food, weight loss, family w/ similar Sx

Chronic diarrhea (>3 wks):

-Watery (sec= retory vs osmotic vs functional)

-Fatty (malabsoptive vs maldiges= tive)

-Inflammatory

Osmotic diarrhea imp= roves with fasting, secretory diarrhea does not.

S= tool osmotic gap =3D 290 =E2=80=93 2x(stool Na + stool K). Used= to distinguish secretory vs osmotic.

-Secretory (stool osm gap &= lt;50): infectious, non-osmotic laxative, microscopic

colit= is, alcoholism, hyperthyroidism, bile salt malabsorption, medication

<= div>-Osmotic (stool osm gap >125): lactose intolerance, sorbitol, antaci= ds,

medication, celiac, SIBO

DDx: = Infectious, celiac disease, SIBO, food intolerance, microscopic colitis, bi= le salt malabsorption, pancreatic insufficiency, IBD, IBS

#Diarrhea

We discussed at length potential= therapies such as a low FODMAP diet, IBgard, fiber supplements, probiotics= , and prebiotics. In addition, she was advised to try levsin SL PRN for blo= ating and cramping as well as immodium PRN to control diarrhea symptoms. Th= e DDx also includes celiac disease, food intolerance, microscopic colitis, = SIBO, infection (e.g. Cdiff), bile acid diarrhea, and pancreatic insufficie= ncy. Thus, we will have ordered tests accordingly (outlined below).

RECOMMENDATIONS

-TTG IgA= and Total IgA to evaluate for celiac disease

-SIBO Breath test

-Stool studies: Fecal elastase, Fecal calprotectin, Cdiff

-Low FODMAP diet

-Start Fiber supplements (We discussed fiberso= urce, benefiber, metaucil, citrucel, fibercon)

-Trial of Pro-biot= ics

-Trial of Pre-biotic sugars (inulin)

-Loperamide PR= N

-IBgard

-Levsin sublingual 0.125mg q4h PRN for bloati= ng/cramping

-Immodium PRN

-Consider colonoscopy with ra= ndom biopsies for microscopic colitis

-Consider cholestyramine, p= ancreatic enzymes (30K units TID), Abx

-RTC 3 months

<= div>

<= /tr>diltiazem/verapamil =3D do not give in HFrEF pt
diuresis

- add m= etolazone / chlorthiazide to augment diuresis, or if hyperNa
- add aceta= zolamide if metabolic alkalosis
- spirinoactone to normalize Kdiverticulitis
- outpt: = cipro/flagyl or watch if not septic or high risk (ecoli high resistan= ce to bactrim, so won't do bactrim+flagyl; augmentin)
- inpt: zosyn+flag= yl (zosyn only for pseudomonas), normally ceftriaxone+flagyl

uncomplicated (75%) marked wit= h abdominal pain, fever, leukocytosis, obstipation/diarrhea/ anorexia. = ;

Complicated (25%): with abscess/ stricture / fis= tula

CT shows sigmoid diverticulosis. <= /div>

Uncomplicated management: - Cipro/flagyl, bactirm/= flagyl, bowel rest, narcotics

Complicated: antibiotics (IV = GNR + anaerobe coverage) bowel rest, narcot,s surgical evaluation (peritoni= its present, evaluation of potential for abscess drainage or colonic resect= ion)

- Colonoscopy to exclude IBD / malignnacy for 6-8 week= s following acute episode

Diving nitrogen in body
- Sx: m= uscle pain, itchy skin, visual issuesm dizzy
- Tx: 100% O2, then hyperba= ricdizziness
-= HINTS exam (if abnormal, urgent brain MRI)
- meclizine if motion sickne= ss of meniere

meniere =3D increased fluid volume/pressure= in ear fluid
Sx: triad of 20m-12 hr episodes and room spinning, h= earing loss in affected ear (happens first), tinnitus
- Tx: thiazide, decrease salt, caffeine, alcohol.

labyrinthitis =3D viral = infection, constant vertigo. (can use prednisone)

BPPV
- Sx: <= 1 minute dizzy when moving head
- dix-hallpike - rotary/horizontal/verti= cal nystagmus; head turned to that side is the affected ear side. on = repeated testing, can decrease= doxorubicin/cisplatin - increases WBC (okay, assess clinical= ly)
- watch for AKIDRESS (drug reaction eosinophilia systemic symptoms)
- by allopurin= ol or antiseizure meds (phenotoin, carbamazepine)
- Sx: rash eruption on= face/upper trunk and goes full body. face edema; fever, diffuse lymphadeno= pathy, multiple organ issue
drowsy/RASS:

duputren contracture
- fibrosis of palmar = fascia
- Sx: fingers MCP flex
- cause unknown, but jobs with repetiti= ve motion, vibration, DM, alcohol, smokingDVT/PE
- Sx: RR, tachy, cough
- score: = ;Wells' Criteria for Pulmonary Embolism - MDCalc (not for rule = out when inpatient per a study); if t low risk according to Wells criteria = with a PERC score (see pic) greater than zero, D-dimer testing should= be performed
- score if confirmed PE: sPESI
- causes: surgery/trauma, imm= ovilization, malignancy, pregnanct, OCP, estrogen, antiphospholipid antibod= y syndrome, HIT, paroxysmal nocturnal hemoglobinuria (if mesenteric thrombu= s), obesity, smoking, nephrotic syndrome, HIV/AIDS, cancer meds, central li= ne
- test: bedside echo for right heart strain (hypokinesis, RV>LV)- Tx: lovenox (faster than heparin to theurapeutic). heparin if severe re= nal insufficiency, high bleed risk, or morbid obese.
- if warfarin, dabi= gatran, then also need lovenox or heparin at the same time for 5 days; for = warfarin until INR is therapeutic for 24 hours
- cancer or pregnancy use= LMWH or heparin (not warfarin), but DOAC better for cancer than LMWH
- = if unstable and low bleed risk, consider thrombolytic
provoked =3D 3 mon= ths; indefinite if cancer if bleed risk is low or unprovoked (can do 6 mont= hs and repeat ultrasound if 1st tiem)
- labs: activated protein C resist= ance, anti-cardiolipin IgA, IgG, IgM, antithrombin III activity, PT/INR, PT= T, factor 8, fibrinogen, homocysteine, lupus anticoagulant refle, protein C= activity, protein S activity, prothrombin gene mutation.
Factor V leide= n is most common hereditary
* protein C, S, and antithrombin III levels = affected by anticoag and clotting, so test 2 weeks after completing anticoa= g (PT, APTT, anticardiolipin assay; confirm with lupus anticoagulant testin= g, ixing study), factor V leiden (protein C resistance assay; confirm with = Factor V study), protein C deficiency (protein C activity), protein S defic= iency (protein S activity), prothombin gene mutation (prothrombin/factor II= analysis), antithrombin II deficiency (antithrombin functional), elevated = factor III activity, hyperhomocysteinemia (homocysteine total level), fibri= nogen

- young person with clot =3D likely factor V leiden =3D protei= n C resistence

- UCI heme-onc: camn get prothrombin gene, factor V l= eiden, beta 2-glycoprotein, cardiolipin Abs first. Lupus anticoagulan= t to check later as false positive when on antico-ag.

SUPERFICIA= L VT with increased risk of progression
=3D extensive SVT, grater saphen= ous vein involvement, thrombus above knee or close to saphenofemoral juncti= on, recent surgery, active cancer, or history of thrombus
- Tx: 45 days = of anticoag.

PPx:
- lovenox 40 mg daily if BMI < 40, BID BMI i= f > 40
- if CrCl <30, heparin 5000 q8-12h
- if HIT, use fondapa= rinux
- if cancer, only lovenox

3-6 months treatment if : VTE ass= ociated with a major transient risk factor, those with unprovoked distal le= g DVT, and those with unprovoked proximal leg DVT who are at high risk for = bleeding
longer if low risk for bleeding and unprovoked proximal

=
- DDx for elevated d-dimer: MI, stroke, DIC, cancer, lung disease, CHF,= renal,
D-dimer <500 =3D normal (sensitive, not specific)= --- unless older than 50 (age x10)

proximal DVT (popliteal, fem, il= iac): DOAC > LMWH
distal PE - serial U/S if high risk of bleed or asy= mptomatic versus anticoag (high risk factor for extension: d-dimer positive= , close to prox veins, >cm)

Chronic thromboembolic pulmonary = hypertension
- if TTE shows RV hypertrophy, elevated mean PA pressure, a= nd enlarged RA, then suspect. VQ scan actually more sensitive than CT= A PE. IF abnormal, need right heart cath and pulm angio

warfar= in: can get necrosis if patient has protein C deficiency; if skin necrosis,= stop warfarin, give protein C
- if warfarin INR > 10, then give vita= min K, else can just hold warfarin and monitor
- if INR high and life-th= reatening bleeding, then PCC and vitamin K (4-factor with II, VII, IX, and = X preferred; there is 3-factor - without VII, but not as good)

if pr= egnant, use the YEARS criteria + d-dimer

!!! After 6 months, if stil= l need DVT due to increased risk factors, half the dose (is shone to be bet= ter)
https://www.nejm.org/doi/10.1056/NEJMoa1207541
https://www.nejm.= org/doi/10.1056/NEJMoa1207541

dyspnea/SOB<= br>- DDx: HF, arrhythmia, pneumonia, pneumothorax, PE
- exertional: CXR,= EKG, Echo, spirometry, if all negative, then stress test
- Opioids are = the first-line option for treatment of dyspnea refractory to maximal medica= l management.

1 hour duoneb (6ml)

Fungitell -beta d glucan. D= oes not test for blasto crypto= ear infection otitis media
- effusion + fever/tympanic in= flammation
by strep pnuemoniae, non-typeable H influenzae, or mora= xolella
- Tx: 1st amoxicillin, 2nd augmentin. if penicillin allergy, cli= nda or azithro

early dumping symdrome:increasing osmotic load to the bowel that ccaus= es dizziness (30 minutes)
late dumping syndrome due to insulin (hypoglyc= emic 1-3 hours)= E= KG arrhy

- QRS > 120
- RBBB =3D bunny ear (rSR') in V1 = , qRs in V6
- LBBB =3D large negative QS in V1, tall R bunny in V= 6

- QTc <440 in male, <460 in female (easy QT if 1/2 of = R-R)
- if BBB, then QTc =3D QT - 0.485xQRS

- hyperCa (less reflex= , decrease GI motility, weakness, urinary incontinence) =3D short QT
- h= ypoCa =3D long QT

- electrical alternans (varying QRS complex) =3D c= ardiac tamponade

- LVH =3D Sokolow-Lyon criteria: S in V1+R in V5 or= V6 =3D 35mm+ or aVL 11mm+; (easier) Cornell criteria: S in in V3 + R= in aVL >28mm in male or > 20 in female
- RVH =3D R>S in V1 OR = R in V1 7+mm and S 7mm+ in V6
- LAE =3D negative P wave in V1
- RAE: = P wave > 2.5mm in II

- AVNRT: has small little r' in V1 or V2 dur= ing tachycardic episode. (Can treat with adenosine 6mg, then 12mg if doesn'= t work)
- AVRT: gets J wave or short PR, then gets a PAC, and starts the= AVRT\

if wide qrs, subtract QRS-120 from Qtc

- olanzapine (i= ncreases QTc the least out of all), Ativan does not. haldol does not = decrease depression
- depakote?

electrolyte
hypoCa
- Sx: carpopedal spasm, l= aryngospasm, bronchospasm, seizures
- EKG: prolonged QT
- iCa <=3D= 0.8mmol/L or Ca <=3D7.5
- if CKD, treat hypophos and vitamin D. = IV calcium not indicated first
- if digoxin, IV Calcium can cause DDI d= igoxin toxicity

hyperCa =3D short QT

hypoK =3D prolong QT, fl= atten T, large U wave
hyperK, peaked T wave, prolonged flat P, wide QRS = if severe
- K has K citrate at UCI

If high K persistent in hospit= al, can be due to heparin. Switch to lovenoxelevated ICP
- repeat CT head in 6 hoursHOB elevation 30 degrees
- CCP goal 60-70 (MAP - ICP)
- ICP non-TBI= <=3D20, if TBI <=3D22
- Na 140-150

If ICP > goal, 3% NS= drip or bolus and/or mannitol 0.5-1g/kg IV q6h (no mannitol if serum osm &= gt; 320)
pupilometers if GCS <=3D3= elevated LFTs / AST/ ALT transaminitis / ALKP

R ratio

if both mildly elevated, can be NAFLD (pt also with= diabetes obesity, HLD(

Primary biliary cholangitis (Age 40-60 m= ore in women)
S&S: pruritis
If ALKP 1.5x upper limit, positive an= ti mitochondrial, or positive SP100/GP210 (order only if anti mitochondrial= negative), then no liver biopsy needed
- Tx: urseodeoxycholic acid
-= screen for TSH yearly, dexa every 2 years, men need HCC screen

PSC<= br>S&S: pruritis, high Tbili, ALKP
Dx: MRCP string of beads
- Tx:= liver transplant
- screen for HCC (annual MRCP and CA 19-9/AFP) and&nbs= p;colon cancer every year,

augmentin/antibiotics, anti= seizure meds, can cause acute liver injury; or liver hypoperfusion (due to = acute hypotension in hospital); if hemoylsis in young patient or psychiatri= c disorder, possibly wilson disease (order serum copper and urine copper.&n= bsp; and serum ceruloplasmin)
if AST/ALT 5000
- also possibly HSV
=

Elevated liver chemistries -

1. Hepatocel= lular injury is defined as disproportionate elevation of AST and ALT levels= as compared with the alkaline phosphatase level.

= 2 . Cholestatic injury is defined as disproportionate elevation in alkaline= phosphatase level as compared with AST and ALT levels.

3 . Mixed pattern of injury is defined as elevation of both alkaline = phosphatase and AST/ALT levels.

4 . Isolated hyper= bilirubinemia is defined as elevation of bilirubin with normal alkaline pho= sphatase and AST/ALT levels.

Severe or massi= ve elevations in liver chemistries could be from: acute viral hepatitis, is= chemic hepatitis/shock liver, septic shock, vascular disorders

in= cluding acute Budd=E2=80=93Chiari syndrome or acute hepatic artery

occlusion, toxin-/medication-induced liver injury, autoimmune

h= epatitis, acute biliary obstruction (choledocholithiasis), diffuse infiltra= tion of the liver

with cancer, liver trauma/surgery, veno-occlusi= ve disease/sinusoidal

obstruction syndrome, HELLP syndrome, and W= ilson=E2=80=99s disease.

Elevated AST and AL= T- Ddx Alcoholic liver disease, Cirrhosis (of any etiology), Ischemic hepat= itis, Congestive hepatopathy, Acute Budd-Chiari syndrome, TPN, NAFLD/Steato= sis/NASH, Chronic viral hepatitis, Acute viral hepatitis, Medications and d= rug-induced liver injury, Prescription medications, Herbal products and sup= plements, Over-the-counter agents, Hemochromatosis, Autoimmune hepatitis, W= ilson=E2=80=99s disease, Alpha-1-antitrypsin deficiency, Celiac disease, Ac= ute bile duct obstruction, Post-liver surgery, Veno-occlusive disease/sinus= oidal obstruction syndrome, Diffuse infiltration of the liver with cancer, = HELLP syndrome, Acute fatty liver of pregnancy, Sepsis.

Elevated unconjugated bilirubin - Ddx Gilbert=E2=80=99s syndrom= e, Hemolysis (intravascular and extravascular), Ineffective erythropoiesis,= Resorption of large hematomas, Hyperthyroidism, Medications, Post-blood tr= ansfusion.

Elevated conjugated hyperbilirubi= nemia - Ddx Bile duct obstruction (Choledocholithiasis, Malignant obstructi= on, Bile duct stricture, AIDS cholangiopathy)

Viral hepatitis, To= xic hepatitis, Medications or drug-induced liver injury, Acute alcoholic he= patitis, Ischemic hepatitis, Cirrhosis, PBC, PSC, Infiltrative diseases of = the liver, Metastatic cancer, Lymphoma, Hepatocellular carcinoma, Wilson di= sease

Autoimmune hepatitis, Ischemic hepatitis, Congestive hepato= pathy, Sepsis, TPN, Intrahepatic cholestasis of pregnancy, Benign post-oper= ative jaundice, ICU or multifactorial jaundice.

El= evated alkaline phosphatase- Bile duct obstruction, Bile duct obstruction, = Primary biliary cirrhosis, PSC, Medications and drug-induced liver injury, = Infiltrative diseases of the liver, Metastatic cancer, Lymphoma, Hepatic ab= scess, HCC, Viral hepatitis, Cirrhosis, Alcoholic liver disease, TPN, Acute= alcoholic hepatitis, Sepsis, Congestive heart failure. Extrahepatic causes= include: Bone disease, Hyperthyroidism, Hyerparathyroidism, Pregnancy (thi= rd trimester), Chronic renal failure, Lymphoma, Extra-hepatic malignancy

- check HBsAg, HBcAb, = HBsAb, HCV Ab

- check ANA, ASMA, gamma-globulin quant, AMA, cerul= oplasmin, alpha-1 antitrypsin phenotype

- test tylenol level (nor= mally AST and ALT 1000)

- check iron level, transferrin sat= uration, and serum ferritin

- For massive ALT elevation >1000:= HBsAg, HBcAb IgM and IgG, HBsAb, HAV IgM and IgG, HCV Ab,HSV, EBV, CMV, ce= ruloplasmin, ANA, ASMA, AMA, IgG, serum drug panel including tylenol level,= and urine toxicology panel

- check abdominal ultrasound with dop= pler

Chronic liver

- Autoimmune pan= el: ANA, ASMA, AMA, IgG

- Viral Hepatitis Panel: Hep A IgM,= Hep A IgG, Hep BsAb, Hep BsAg, Hep BcAb, Hep C Ab (do not use acute hepati= tis panel as this does not include all needed values)

- Met= abolic panel: Ceruloplasmin, A1AT, iron studies including Ferritin

- Last ultrasound

- Last AFP (liver cancer)

- Last fibroscan

#Hepatocellul= ar injury: R ratio > 5 suggestive of hepatocellular injury. May be relat= ed to pancreatitis but cannot rule out other causes.

- UTOX

- Ethanol

- Viral hepatitis panel

- HIV = ;

- Can consider CMV, EBV, VZV, HSV if transaminitis persists bey= odn treatment of pancreatitis.

- Less likely could be celia= c disease (anti-TTG, total IGA), hemochromatosis, Wilson's (decreased cerul= opasmin, increased urine copper)

. - CMV, EBV, VZV, HSV for other viral c= auses of transaminitis

- Anti TTG, total IgA for cel= iac's. Consider endomysial given high specificity if this is positive. = ;

- FU iron panel nad ferritin Fe/TIBC:> 45% and ferritin >= 200 should warrant HFE testing (often diagnosed in those 40+, with women m= anifesting symptoms later than males)

- Ceruloplasmin, urine Cu f= or wilson's (hemolytic anemia from sudden release of copper and altered men= tal status supports this)

- ECHO for evaluation of congesti= ve hepatopathy

- ANA, ASMA, AMA, LKM1 serologies, SPEP for = AIH evaluation

- RUQ US for fatty liver

- U= tox for cocaine, ecstacy, PCP

Ischemia likely give= n recent shock, cardiac arrest, history of Budd Chiari. Can consider rarer = causes such as autoimmune hepatitis, acute Wilson's, HELLP syndrome, alcoho= lic hepatitis, malignant infiltration.

- LDH -- ALT: LDH ra= tio <1.5 suggestive of ischemia/APAP toxicity over viral hepatitis. = ;

- Continue to monitor bilirubin -- often will see a peak in 1 w= eek later after a 48 hr acute rise in ALT/AST.

- Acetaminop= hen level

- Hepatitis panel, total hepatitis B antibody, HS= V, VZV, EBV, CMV to evaluate for acute viral infection

nyha

#cholestatic injury: R ratio <2= with elevated alk phos and bili. Ddx includes bile duct obstruction (malig= nancy, ascneidng cholangitis, PSC, PBC, chronic pancreatitis with stricture= s), cirrhosis, medications.

- Hepatitis panel

- R= UQUS for obstruciton

- AMA

<= div>#infiltrative pattern of liver injury: alk phos elevated to ***. Ddx in= cludes sarcoidosis, granulomatous diseases, amyloidosis, malignancy. Alk ph= os is als ofound in bone (bony mets), intesitns (increased in SBO).

- GGT -- if high concern for liver source -- test fractionated alk= phos (bone gut hepatic)

- Consider SPEP

Indirect hyperbilirubinemia: consider Gilbert's, hemolysis, resorpti= on of large hematoma.

if women 20-40, = high likelihood autoimmune hepatitis

- IgG level, positive ANA, a= ntismooth, positive pANCA

- will need liver biopsy to confirm dia= gnosis

- Tx: steroid and azathioprine

endocarditis
Duke criteria: https://www.mdcalc.com/calc= /1731/duke-criteria-infective-endocarditis
- suspect if history of heart= valve, heart transplant, any heart surgeries
- HACEK bacteria: haemophi= lis, aggregati/actinobacillus, cardio, eikenella, kingella
- Sx: osler n= ode =3D painful red-purple papule or pustule located on digit or hands/feet= ; roth spot - hemorrhage in retina eyes, focal neurologic sign (septic embo= li), splinter hemorrhage on nails
- Dx: TTE ,consider TEEEndocarditis
Need surgery if = not responding to tx for 5-7 days with persistent bacteremia , >1cm, and= abscess
enol= ase for brain anoxic injury - high specificity

anoxic brain in= jury post arrest - studies show MAP > 85 bettereosinophilic esophagitis
- Sx: solid fo= od dysphagia
- biopsy eosinophil count 15+/hpf
- Tx: PPI and swallow = steroidepididymi= tis
- <35 - treat gonorrhea and chlamydia (doxy + CTX)
- >35 wi= th levofloxacin. If having sex, CTX + oral levo.

prostatitis- levo or bactrim for 2-6 weeks
- if hospitalized, gentamicin + levo o= r CTXESBL
- ca= rbapenem
- if oral for simple UTI, nitrofurantoin (Zosyn IV only for mil= d case) or Bactrim is 1st line; fosfomycin also
- duration 7 daysesophageal dysphag= ia
- cause: mechanical obstruction (solids) or motility (liquid or liqui= d and solid)

- dysphagia includes GERD, esophageal stricture/ring, = CP bar, obstructive mass, LES dysfunction, diverticulum. If motility = component, it could be secondary to spasm, dysfunctional LES relaxation, ac= halasia.

= esophagitis
- S&S: odynophagia (painful swallowing= )
- most likely candida, then CMV, and HSV
- can also be pill induced= : NSAID, tetracycline, KCL, iron, alendronatefall on outstretched hand

scaphoid fra= cture
- initial XR can be negative, MRI (better) or split with repeat XR= in 2 weeks
- if not treated, can become non-union and distal radius deg= enerates =3D arthritisfalls
- 1 fall in past year needs Up and Go test. >12 seconds ne= eds referral to PTfast heart rate
esmolol dripfever > 104F
malignant hypertehermia (due to anesthe= sia) =3D masster muscle rigid, high ABG pCO2 - Tx: dantrolene
- neurolep= tic malignant syndrome (haldol, seroquel, withdrawal from levodopa - happen= s in days/weeks - gets altered and very rigid. Tx: dantrolene and bromocrip= tine
serotonin syndrome =3D rigidity, agitatoin, very reflex, myoclonus = - benzo, cyprohepatdineflu
- from MKSAP, still start tamiflu but normally, just 48 hours= onset.foot pain<= br>- morton neuroma =3D pain between third and 4th toe caused by wearing ti= ght shoes. pressing on it will hurt;. Tx: arch support and wide shoes=
foot

= stress fractures
- point tenderness, relieved with rest
- walking boo= t (no need casting for stress fractures), or splint or hard shoe
- MRI i= f XR doesn't show

plantar fasciitis
- pain first few steps in mor= ning, pain at medial calcaneal tubercle with palpation or passive dosiflexi= on of toesgallsto= ne - need = g= astroparesis

#Ga= stroparesis: Patient's ongoing nausea, vomiting, early satiety, postprandia= l fullness, bloating, and upper abdominal pain concerning for gastroparesis= . Diagnosed officially by delayed gastric emptying in the absence of mechan= ical obstruction. Ddx includes gastritis secondary to H PYlori inefection p= eptic ulcer, and functional dyspepsia. A1C of *** -- sugars >200 have be= en shown to delay gastric emptying.

- Trial prokinetic agen= ts: metoclopramide, erythromycin (more appropriate for short term use) = ;

- Can consider gastric electrical stimulation in outpatient set= ting

- Consider domperidone

- Consider centrally = acting antidepressants

- Mirtazapine 7.5 mg q HS (caution= with concurrent SSRI)

- Second line approaches include ve= nting gastrostomy, feeding jejunostomy

<= div>

Secondary to diabetes. A gastric emptying scan was diagnostic of g= astroparesis in * Ddx includes rumination syndrome, eating disorders,= cannabinoid induced hyperemesis, cyclic vomiting syndrome, GERD, gastric o= utlet obstruction etc. Prior work up includes EGD done in *. Patient was pr= eviously treated with reglan, zofran, compazine* This patient has had frequ= ent admissions and exacerbations likely triggered by uncontrolled diabetes*= and opioid medications. This patients BMI is currently *.

- Markedly uncontrolled ( > 200 mg / dl) glucose levels m= ay aggravate symptoms of gastroparesis and delay gastric emptying. Optimiza= tion of glycemic control should be a target for therapy; this may improve s= ymptoms and the delayed gastric emptying.

- Medication-induced de= lay in gastric emptying, particularly from narcotics and anticholinergic ag= ents and glucagon like peptide-1 (GLP-1) and amylin analogs should be stopp= ed.

- The first line of management for gastroparesis patients sho= uld include restoration of fluids and electrolytes, nutritional support and= in diabetics, optimization of glycemic control.

- Oral intake is= preferable for nutrition and hydration. Patients should receive counseling= from a dietician regarding consumption of a "gastroparesis diet": frequent= small volume nutrient meals that are low in fat and soluble fiber. If unab= le to tolerate solid food, then use of homogenized or liquid nutrient meals= is recommended.

-Oral intake is the preferable ro= ute for nutrition and hydration. If oral intake is insufficient, then enter= al alimentation by jejunostomy tube feeding should be pursued (after a tria= l

of nasoenteric tube feeding). Indications for enteral nutrition= include unintentional loss of 10 % or more of the usual bodyweight during = a period of 3 =E2=80=93 6 months, and / or repeated hospitalizations for re= fractory symptoms.

- For enteral alimentation, postpyloric = feeding is preferable to gastric feeding because gastric delivery can be as= sociated with erratic nutritional support.

- Check= EKG to measure QTc

- Metoclopramide is the first line of prokine= tic therapy and should be administered at the lowest effective dose in a li= quid formation to facilitate absorption. The risk of tardive dyskinesia has= been estimated to be < 1% but may be irreversable, there is a black box= warning for this. Patients should be instructed to discontinue therapy if = they develop side effects including involuntary movements.

= - Reglan 5=E2=80=9310 mg AC BID-TID can start with IV and transition to PO&= nbsp;

- Erythromycin improves gastric emptying and symptoms from = delayed gastric emptying. Administration of intravenous (IV) erythromycin s= hould be considered when IV prokinetic therapy is needed in hospitalized pa= tients. (Erythromycin 250=E2=80=93500 mg ac t.i.d.)

- Schedule an= tiemetics around the clock

- We do not offer gastric electrical s= timulators at UCI, the patient will need to follow up at another center as = an outpatient for this

= ge= riatrics:
- semitandem, tandem, one leg - risk of falls
- cut off for= proximal; 30-second chair stand
- STEDI toolkit
- BP and weight can = be home RN
- medstopper.com
- donepezil: urinary inconteinence side e= ffect
- SNF should have tapering for psychotroppic meds
- try to tape= r all beers
- cipro for old people can cause confusion if renal
- wha= t is most important to you (function, enjoyingm connecting_; what concerns = you about your health in the future
- POLST only if DNR (assisting livin= g, SNF, board require it)
- ARU: needs 2 skilled needs
- medicare/pri= vate: 100% for 20 days, then 80% for rest 80 days (100 days total) - copay = ~$176/day after (medicaid will take the copay). (- medicare A: need 3= midnights to qualify for medicare part A; observation time doesn't count);= can go to SNF again 60 days after.
- long term care; custodial care: co= vered by medical only. (ADLs; normally fecal incontinence)
- SNF p= hysician needs to see only within 72 hours (only have tramadol PRN in= their emergencyh kit; need 3 days of opioids***); SNF physician only need = to see after once a month
- SNF < beds, 1 RN per day shif (1RN per 40= beds); >99, 1 RN per each shift; mostly LVN, few RNs
- if med is too= expensive; may be denied (as takes from their final pay)
- continue DVT= ppx; No IV pain meds
- psych meds need indication/diagnosis and consent= from family (medicare monitors this to SNF)
- SNF has, dopller U/S, por= table xray, urine, labs. stool (ndont' do misc labs); no CPAP/BIPAP provide= d -- or hospital need to give for discharge
- SNF does not have to have = defibrillator (advocate for lifevest if going to SNF)
- SNF to appointme= nt patient covers by self; exception some HMOs has this benefit
- do not= need a primary care appointment until after SNF discharge (SNF MD should c= are)
- no RT on site
- wound pressure stage3 and 4 cannot go to assis= ted living or board and care
- residential care for the elderly form (AL= F - rent and food; anything else laundry is extra; or board and care - not = more than 6 people; 24 hour living care giviners; but only does things in t= he day shift -- no medical staff)

IADLS: telephone, shopping, cooking, housekeeping= , laundry, medications, finances, driving
bathing, dressing, feeding, toileting,= incontinence, transferring
gi cocktail aloh/mgoh/simheticone with viscous lidoca= ine 15cc (Mylanta/maalox)GIP
- can increase versed to 39gitelman syndrome
- S&S: young adult/teen,= with low BP, low K, high CO3, high Ca
vs. Bartter sydnrome - presents a= s childglycopyrol= late to decrease secretion in comfort care

gonorrhea
- disseminated gonorrhea: - = pustular/vesiculopustular at extremities, painless, tenosynovitis and polya= rthralgia, with fevergood resources:
- b line https://www.grepmed.com/images/11922/l= ung-diagnosis-profiles-ultrasound-abcsgout
- NSAID + choclicine + steroid (20-30mg predn= isone (do weight based too though)) when acute flare
- allopurinol when = not in flare (start colchicine too when on allopurinol; can stop in 3 month= s)
- febuxostat (not in acute too) if cannot take allopurinol (very bad = CKD)
- no colchicine in kidnery failure patients
- colchicine only wo= rks for first 2 days of acute flare
- uric acid goal <6, <5 if top= hi
- 2 episodes in 1 yr needs ppx

No nsaid in ckd, chf
- if cannot do any of the acute tx, then anakinra and/or cosyntropin

gout
- u= ric acid may not show in acute
- uric acid therapy:
- NSAIDs, colchic= ine, prednisone

- Tx: allopurinol (don't start during acute fl= are)
1) tophi, goal uric acid < 5
2) erosions of bone
3) 2 or m= ore gout flares
4) CKD3 and uric acid > 9grief-depression in pallative
- if <6 = weeks onset, use methylphenidate. benzo for anxietygroup A strep / strep throat
- Sx: ton= silar exudate, anterior neck lymph, fever
- tx duration: 10 days (amoxic= illin or penicillin)

rheumatic fever
- Sx: erythema marginatu= m skin
- 2-4 weeks after

post-strep GN
- tea colored urine (he= maturia)
- low C3 (and C4)
- Tx: supportive care, diuretic, BP medsgynecomastia
-&= nbsp;estradiol, total testosterone, luteinizing hormone, and =CE=B2-human c= horionic gonadotropin level
- Unilateral, nontender, or fixed breas= t masses in a man should prompt an evaluation for breast cancer with a mamm= ogram.hHAP
- Dx criteria: 48 h= ours since admission= Headache
- MRI if first/worst migraine, persistent (>72hrs)
- = risk of overuse NSAID causes
- tx: Naproxen 500 or ibuprofen 600

= - intracranial hypotension =3D S&S: posturalheadache, diplopia, tinnitu= s, photophobia. CSF opening pressure <60 mmH20 will see some= meningeal enhacement possibly small cerebellla tonsillar dscent.&nbs= p; Tx: epidural blood patch

Tension
- preventative: ami= triptyline

Migraine
- dx criteria: ICHD-3; chronic =3D 15+ = episodes
- tx: NSAID, rizatriptan q1-2h faster onset and fewer si= de effects than sumatriptan (no triptan in CAD, PAD, ischemic stroke). nara= triptan q4h also good - longer acting, slower onset. Triptan can cause ches= t tightness (let patient know). -diptan if CAD/PAD, but causes dizziness. <= br>Preventative (if 4+ episodes): propranolol, metoprolol, topiramate (S= E if long term use: kidney stone, foggy brain), valproate, venlafaxine = but SE. If fail 2 triptan, insurance covers -gepants (CGRP receptor blocker= ) and CGRP Ab Gepants.
- Tx: metoclopramide 10mg IV also good
-&= nbsp; triptans are contraindicated in the setting of brainstem or hemiplegi= c auras. !!! no triptan if CAD or stroke

Nausea c= aused by migraine - try metoclopramide or prochlorperazine (Compazine)
<= br>"Trial migraine cocktail q6h PRN: 1L fluid bolus, toradol, benadryl and = zofran"

severe migraine:
1L bolus of IV normal saline solution

10 mg = of IV prochlorperazine

25 mg of IV diphenhydramine

30 mg of I= V ketorolac

10 mg of IV dexamethasone

Olanzapine also w= orks for nausea

he said: 15 toraldol , topamax 25mg, 10mg reglan, 10= mg prolchlorperazine, 2g Mag, 10mg IV dex (make sure QTC is okay)
=

outpatient:
- quilipta for chronic migraines abortive and pr= eventative (needs prior auth)
- nurtec for episode migraines (needs prio= r auth)
- Froba for menstrual-induced migraines (longer active)

<= br>Chronic migraine =3D 15x/month
status migrainosus =3D last >72 hou= rs with or without aura

Cluster headache:
- periorbital and= temporal with lacrimation, ptosis, and rhinorrhea. last 15-180 minutes onl= y.
- Tx: O2; verapamil for prevention

Differential includes primary headache such as mig= raine vs tension headache. Doubt subarachnoid hemorrhage, headache not maxi= mal at onset, not worst headache of life, and patient has normal neurologic= exam. Doubt meningitis or encephalitis, no infectious symptoms or meningis= mus on exam. Doubt acute angle glaucoma, no vision changes or eye pain. Dou= bt temporal arteritis.

heartburn / dyspepsia
- c= ause: idiopathic (75%), cancer, H pylori, NSAID, bisphosphonate
- Tx: tr= ial famotidine, but if not better, H pylori testing if <60. if >60 yr= s old, EGD

- test all pts with PUD for H pylori
H pylori test= can be negative if taking PPI or antibiotics; stop 4 weeks antibiotics and= 2 weeks for PPI for H pylori testing

KCL can cause non-ulcer dy= spepsia (stomach pain)
hematoma:
subdural hematoma - from bridding veins, common in ol= der ageheme issu= es

G6PD
- bite cells, confim with G6PD level

Microangiopat= hic hemolytic anemia
- helmet cells

thalassemia
- target cells= hemophilia C (fa= ctor 11 deficiency) comon in Ashkenazi Jew ---
- only aPTT is prolonged = (no easy bleeding symptoms, but only post-surgical prolonged bleeding)
-= Dx: factor levelshemoptysis
- causes: bronchitis, bronchiectasis, cancer, trauma, infec= tion (pneumonia, abscess, TB), vasculitis (ANCA, anti-GBM), coagulopathy, P= E
- CXR, CBC, coag, UA, sputum Cx, CTA chest if stablehemoptysis
- CT with contrast, i= f negative, bronchoscopy
- cause: infection, bronchitis, malignancy= heparin
BM= I > 40 (versus UCI says 70kg) - q8hhepatic adenoma
- if >5cm or in male, remove as = high risk of transforming to cancer)
- for women, discontinue oral contr= aceptive and follow up with CT/MRI at 6 monthhepatic encephalopathy
- lactulose 3-4 BMS= per day
- rifaximin if still not resolvedhepatitis C
- need q6m ultrasound to asses= s for HCC (+/- AFP too)
- hepatitis C: can also get vasculitis - HCV-ass= ociated mixed cryoglobulinemia =3D shows as recurrent purpuric very purple = spotty lesions on foot

- A= cute HepB, even if ALT/AST very high at 1000-2000s and jaundice, just have = outpatient serial labs - no need to admit. HepB low risk of liver fai= lure. If having encephalopathy AND INR 1.5+, then admit to ICU due to= acute liver failiure.

- HepB with HepC, need antiviral

- HepB, adult= progressing to chronic HepB is 5%. Kids 1-5 with acute HepB, 20-50% = become chronic HepB

- hepatitis B that is infection in reactivatin= o phase, pt who is immunosupressed: treat with entecavir or tenofovoir
<= br>Hereditary he= mochromatosis
- OA at early age or at joints that shouldn't be for OA, h= igher AST/ALT, serum ferritin, and transferrin level
- Dx: test HFE gene= mutationhigh out= put GI fistula:
- Tx: subQ/IV octreotide histoplasma:
- disseminated: ampo B&nb= sp; (histo urine antigen very good for disseminated)
- if local: itracon= azole

fungal pneumonia chest pain/pleuritic is normally longer than = acute (e.g. 2 months)
fungal infections get pancytopenia

HIT
- change to bivali= rudin or fondaparinuxHIV

- F/u aspergillus, 1,3 beta D glucan, histoplasma, cryptococcus= , blastomyces, LDH, coccidioides, AFB, blood cultures, sputum culture, NAAT= , C diff, stool culture, stool O+P, PJP, cryptosporidium, isospora, giardia= lambia

- Ophthalmology exam (for CMV retinitis)

= hi= v
- if patient has cryptococcal (and TB meninigitis), don't start ART ri= ght away , but 2 weeks after antifungal therapy starting; monitor for= ICP and immune reconstitution inflammatory syndrome
- to start abacavir= , need HLA-B57:01 testing to be negative to reduce risk of hypersensitivity=

- crypto meningitis daily LPsHLD
- LDL 190+, high intensity statin; need 50% red= uction, else ezetimibe and then PCSK9 Ab
- any MI, stroke, PAD, CABG, st= able angina, ACS if <75 yr old =3D high intensity statin, else moderate<= br>- if diabetes and 40-75, mod intensity (consider high intensity if ASCVD= 20%+)
- ASCVD > 7.5%, mod intensity (CKD, metabolic syndrome, rheum/= inflammatory disease, south asian, LDL 160+, trig 175+)

- LFt before= starting statin, if symptoms, then measure again (else no need). If = elevated 3x, hold statin if concerned of cause

stroke/with CAD or PA= D, LDL goal < 55
Triglyceride 500+, persistent
- Tx: fenofibrate
Eruptive xanthoma =3D on extensor surfaces

#metabolic syndrome: Patient mets = 3/5 criteria (HTN on medication or >130/85, diabetes on medication or fa= sting glucose> 100, waist circumference >40 for M, >35 for F, HDL = <40 for M <50 for F, TG>150)

#Overweight (BMI 25-2= 9.9), Obesity (BMI>30), Severe Obesity (BMI > 40)

- f= /u lipid panel

- Initiate statin

- Can cons= ider Vascepa in outpatient setting for further TG reduction

- CoQ= Enzyme for reduction in myalgias

- Vitamin D level -- "sup= plementation with vitamin D in patients who were vitamin D deficient and al= so had statin-related myositis=E2=80=93myalgia resulted in considerably mor= e patients able to restart statin treatment" (N. Katsiki, V.G. Athyros, A. = Karagiannis & D.P. Mikhailidis (2011) Vitamin D deficiency, statin-rela= ted myopathy and other links with vascular risk, Current Medical Research a= nd Opinion, 27:9, 1691-1692, DOI: 10.1185/03007995.2011.598922 )

= - Can consider metformin in outpatient setting for weight loss in setting o= f metabolic syndrome \

- Consider pharmacotherapy if BMI > 30 = or BMI > 27 with 1+ comorbidity -- ask PCP at time of discharge about me= tformin, liraglutide, orlistat, qsymia .

Consider bariatric= surgery evaluation if BMI>40 or BMI>35 with comorbidities

- Recommend weight loss given multiple RF -- can copy and paste the f= ollowing in discharge paperwork:

HLH (hemophagocytic lymphohi= siocytosis)
- mass macrophages and cytotoxic T cells activated
- Feve= r, low HGb, plt, HGb, ANC, high trig, low fibrinogen, IL2R high, AKI, high = D-dimer

(need to treat underlying) 3D""

hos= pice
- need FAST score of 7 to qualify for hspice care (Http://www.mcisc= reen.com/pdf/fast_overview.pdf)
= HTN - hypertensive emergency
- cause of urgency: pain,= anxiety, urinary retention, steroids, other med SE

HTN emergency- end organ damage: severe headache, seizure, altered, TIA, CVA< papill= edema, pulmonary edema, MI, microangiopathic hemolytic anemia (hemolysis fr= om shearing), AKI, hematuria

HTN
- causes: NSAIDs, OTC decogestan= t, med adherence, obesity, snoring, renal disease, primary aldosternoism (l= ow K, high Na; aldo-renin ratio > 30 in AM), renal artery stenosis (50% = rise in Cr after ACEI start; order duplex U/S)
- Goal for gradual BP red= uction, 20% reduction within the first hour and then goal for 160/100 mmHg-= - for the next 2-6 hours with cautious reduction to normal BP within the ne= xt 24-48 hours.

If labetalol doesn't work, can add on ni= troprusside

2nd causes: renin aldosteron most common (Need to hold a= ce/arb)
- ER: nifedipine ER faster than amlopidine (takes 5+ days)
HTN outpt:
- masked hypertension (i.e. normal in office, high at home)= , antihypertensive medication should be initiated after a 3-month trial of = lifestyle modification if daytime ambulatory or home blood pressure remains= =E2=89=A5130/80
- 1st line HCTZ/chlorthalidone (UCI start losartan50-HC= TZ 12.5), 2nd amlodipine, 3rd line replace HCTZ with chlorthalidone (= more hypoK risk), 4th, spirinolactone or bisoprolol

Aldo renin cut o= ff 30
Hold spirinolactone- increases renin and retest

rule ou= t PRESS (ataxia, headache, HTN)

Saw at LBM: enalapril after la= betalol (no evidence)

"Patient's blood pressure is *** and remains elevated on at least 2 o= ffice visits and categorized as normal (<120/80) // elevated (120-129/&l= t;80) // Stage 1 (130-139/80-89) // Stage 2 (>140/90) // Resistant (on 3= or more agents at optimal doses, with one being a diuretic, or controlled = on 4+ meds)

- f/u fasting blood glucose, LIP= ID PROFILE (cardiovascular comorbidity)

- CBC (polycythemia) Seru= m sodium potassium and calcium (Cushing, Conn, hyperparathyroisim) TSH (2/2= cause)

- Cystatin C/GFR, UA, ECG, ECHO, urinary albumin/Cr = (target organ damage)

Other secondary causes of H= TN

- Renal u/s (Renal parenchymal disease / CKD):

- Renal duplex or MRA or abdominal CT (renovascular disease)

- P= lasma aldosterone / renin ratio (primary hyperaldosteronism is >20)

- Sleep study (OSA)

- 24H urinary metanephrines (pheochromo= cytoma)

- Overnight 1mg dexamethasone suppression test (Cushing)<= /div>

- TSH

- Ca

- ILGF1 (acromegaly)

- Aldosterone and renin levels (mineralocorticoid excess)

- Ec= hocardiography (coarctation of aorta)

Plan: <= /div>

Hypertension: ASCVD risk ***. Goal of <130/80 (<140/90 if s= econdary stroke prevention)

- <10% and less than 140/90 = can be managed with lifestyle changes as if has no significant comorbiditie= s (DM, CKD, HF, PAD, lacunar CVA)

- Start thiazide

- Start on ace/arb given albuminuria

- Start on 2 a= gents given stage 2 BP.

- Black: thiazides or CCB

- Stable ischemic heart dsiease: beta blocker + ace / arb (+dihydrop= yridine CCB if HTN and angina uncontrolled -- more smooth muscle effect... = NOT diltaiazem or verapamil)

- HFrEF: loop diuretic + ACEI + beta= blocker (NO CCBs... consider spironolactone if LVEF <35%)

- HFpEF: diuretics (+acei or ARB plus beta blocker)

- CK= D: if albuminuria present: ACE (thiazides ineffective if GFR <30... use = loop diuretic)

#hypertensive urgency: HTN urgency givne BP >180/20 without= evidnece of end organ damage. Hypertensive emergency BP > 180/120 with = evidence of end-organ damage.

- Reduce BP to <160/100 ov= er the course of the day

- Reduce to normal range (<130/= 90)

- Patient able to tolerate PO: Captopril, laneatlol >= ;> hydralazine given more predictability

- IV: labetalol, hydr= alazine, nitropaste

HTN due to pulmonary edem= a: nitroglycerin and nitroprusside (no beta blockers!)hydrocortisone + florinef shows bene= fit over just hydrocoritone q8h 100 mg for stress dosehyperaldosterone
- S:S resistive= HTN even with 3 drug therapy.
- Dx: aldo/renin ratio >20 and aldo 15= +ng/dL =3D primary hyperaldo
- refer to endocrine/nephrology
- Tx: ep= lerenone (aldosterone receptor blocker) or spirinolactone

Can try sa= lt load if not conclusivehyperCalcemia
- Dx: PTH, phosphate (would be low in primary hype= rparathyroid, high in multiple myeloma), Cr, 24-OH vitamin D, TSH, FRee T4 = (hyperthyroid stimulates osteoclast)
- rule out sarcoidosis; test urine = Calcium ; also rules out familial hypocalciuric hypercalcemia.
- check f= or MEN1
- acute Tx (if > 14): normal saline (don't give diuretic unle= ss patient hypervolemic and has HF or kidney failure); if caused by sarcoid= osis or multiple myeloma or B cell lymphoma, add steroid. Also IV bis= ophosphonate
- long term Tx: bisphosphante

#Hypercalcemia

Ensure corre= ction for albumin -- mild (Ca<12) moderate (12-14), severe (>14). Cli= nical manifestation include MSK -- osteitis fibrosa cystica, bone pain, wea= kness, renal -- polydipsia, polyuria, nephrolithiasis, type 1 RTA, AKI/CKD,= GI-- anorexia, constipation, ileus, pancreatitis -- psychiatric findings i= ncluding fatigue -- depression, anxiety, cognitive dysfunction, coma, stupo= r -- and CV findings such as bradycardia, short qtc, AV block

- PTH to determine if this is related to elevated PTH (pr= imary HPTH (adenoma > hyperplasia > carcinoma), FHH (24 hr urine calc= ium/cr ratio <0.01 or UCCR > 0.01), tertiary HPTH, or ectopic PTH. Lo= w PTH etiolgoies include increased PTHRP (ectopic production from malignanc= y), increased calcitriol levels (lymphoma, granulomatous disease), increase= d ergocalciferol (vitamin D toxicity), and other etiologies including multi= ple myeloma, hyperthyroidism, adrenal insufficiency, pheochromocytoma, drug= s (thiazides, lithium) and milk-alkali syndrome

- Mild to m= oderate hypercalcemia can be managed outpatient

- Severe hy= percalcemia needs treatment.

- Conservative measures:

= - Oral hydration

- Oral PO4 repletion to go= al 2.5-3 (IV can precipitate hypocal

- Volume resuscitatio= n: bolus NS then gtt @ 200-300 cc/hr

- Loop diuretics only = if ocncurrent HF or CKD

- Calcitonin 4-8U/kg SC BID for 48 hours = (lowers Ca by 1-2 ) Beware tachyphylaxis in 48 - 72 hours

-= Bisphosphonates to be used in setting of malingnacy, zolendronate preferre= d. Takes 2-4 D. Ensure 25 OH D repletion prior to admin. Avoid if CrCl <= 30

- Denosumab can be used in bisphosphonate refractory hy= percalcemia

- Glucocorticoids is effective in calcitriol [1= ,25-OH-vit D]-mediated etiologies

- HD if refractory or life-thre= atening

- If primary hyperparathyroidism -- surgery is curative.&= nbsp;

Indicated if (a) symptomatic OR (b) asymptomatic with Ca &g= t; 11.5,osteoporosis/vertebral fracture, CCl < 60, nephrolithiasis, or a= ge < 50.

- If poor surgical cand., consider cinacalcet, = bisphos., tamoxifen

Hyperglycemia/DKA
- if just = hyperglycemia, then fluids a lot first before starting more insulin that ho= me dose.

- b-OH > 3.5 or 4 with acidosis

- DKA: bicarb <= ;=3D15, ABG p H <7=3D7.3, glucose > 250, ketone
HHS: glucose > = 600, can be normal other labs - Tx: give a LOT of fluids

causes of D= KA/HHS
- infection, ischemia, inflammation, intoxication, insulin defici= ency (non compliance, lasix, steroids, etc.)

#DKA: A1C of *** Na of 141 corrected for gluco= se on admission. K of 3.1. Glu of 378. Home meds: on

- LR @ 200 c= c/hr

- If K<3.3, hold insulin and give 20-40 meq IV K. R= estart insulin drip on recheck.

- If K 3.3 - 5.3, add 20 mq= K to IVF

- If K >5.3, continue to monitor K q 2 hrs.&nb= sp;

- BMP q 4 hrs

- Mg q 4 hrs

- = Phos q 4 hrs, replete Phos only if <1

- Beta hydroxybuty= rate q 12 hours

- If pH<6.9, give 2 amps of HCO3. <= /div>

- f/u TSH

- Transition ot subq insulin if BG<2= 00 AND pt is able to eat AND two of the following are met: AG <12, HCO3&= gt;15, pH>7.3.

- Add D5 to fluid to maintain insulin dri= p if sugars < 200 in order to maintain 2 HOUR OVERLAP with subq insulin = (long acting (some say 0.1units/kg vs calculate)

- bolus&nb= sp;

- D10 if BG < 150 and gap not closed and decrease insulin = to 0.5cc/kg/hr

- Diabetes educator

- NPO for now = until glucose <200

hyperkale= mia
- mild =3D 5-6 (furosemide / kayexalate)
- moderate =3D 6-7 (glyc= ose+insulin, sodium bicarb, neb albuterol)
- severe =3D 7

-= Kayexalate (polystyrene sulfonate) 15mg PO QD-QID
- lasix 10mg (low dos= e)
- Lokelma
- patiromer
- if need to continnue ACEI/ARB, then pat= iromer also

- EKG: wide QRS, peaked T waves
- Tx: give CaCl if se= e T waves

- sodium bicarb decreases K and Ca

hypoK
- S= x: decreased reflex, arrhythmia, PVCs, can cause torsades; causes kidney to= not respond to ADH =3D peeing a lot and thirsty

- repeat EKG
- low potassium die= t
- EKG= hypernatremia
- score: Free Water Deficit in Hyper= natremia - MDCalc
- Causes: water loss (GI loss, central/nephrogenic= diabetes insipidus, osmotic diuresis, DKA, manitol), hypothalamic lesion, = severe exercise/seizure, eating too much salt

-both hyponatremia= and hypernatremia male: 0.6 x ([Na)-140]/140; female =3D 0.5

<= td spellcheck=3D"false" contenteditable=3D"true">- serum Osm, urine Na, uri= ne Osm
- CT head to r/o brain lesion
- UA with UCx
- D5W 1.35c/hr = x pt's wt (kg), goal lowe rNa 10mEq/L in 24 hours i.e. 0.4mEq/L/hr (max <= ;0.5mEq/L/hr to prevent cerebral edema)
- BMP q4h (what for K, Na, hyper= glycemia on D5W)

#Hypernatremia: Free water deficit: *** --= then calculate rate of free water replacement using http://www.nephromatic= .com/sodium_correction.php Likely due to impaired access= to free water vs impaired thirst. PO free water

- NGT 200-= 400 mL q 6-8 hours

Or IV D5W

May need DDAVP for DI with enodcrine xx

- BMP q 4 hours

Likely due to free wat= er loss in excess of NaCl loss. Likely due to imapried access to free water= or imapried thirst.

Decreased urinary concentrating abilit= y of DI (decreasd ADH)

RENAL LOSSES:UOsm <= ; 700 -- post ATN diuresis, osmotic diuresisis, DI, loop diuretic, elderly&= nbsp;

Extrarenal losses: Uosm > 700 -- GI loss = from NGT, vomiting, diarrhea, hypodipsia

= hyper= parathyroidism
- hyperCa, if T<-2.5 / lumbar and thoracic spine show = fracture, would need parathyroidectomy only if age <50 and symptomatic- regular folllow up with Ca, Cr, and DEXA
- Tx: cinacalcet (decrease = PTH) + bisphosphonate (block bone breakdown)hypertonic saline - only if someone has bronc= hiectasis; h= ypertrophic cardiomyopathy (HCM)
- squatting (increase pre and afterload= ) decreases obstruction and decreases murur
- Tx: metoprolol succ
- != !! do not give diuretics, vasodilators, or digoxinhypoadrenal
- -S&S: weight loss, l= ow sugar, hyperpigmentation & hypoNa and hyperK (in primary adrenal), h= yperCa
- Dx 8 AM cortisol: <3ug/dL confirms diagnosis. >18ug/dL ex= cludes. if mmorning ACTH high, adrenal CT. if morning ACTH low or mor= mal, pituitary MRI
- if needed, stim test with ACTH. if cortisol &= gt;18ug/DL, then negative
- Tx if acute, don't test - just empirica give= high dose 4mg dexamethasone and IV fluids. !! dexamethasone does not= interfere with serum cortisol assay interesting!

- Tx: hydocortison= e 15-25mg/day, increase 2-10x if stress or minor surgery; add fludocortison= e if primary adrenal insufficiency
- hydrocortisone 100mg followed by 50= mg q6h for major surgery/stress.
hypocalcemia
- CaCl 1g =3D 3 g Cagluconate= hypocalcemia
- c= auses: vitamin D, low Mg, pancreatitis, rhabdo, CKD, tumor lysis
- Dx: P= TH, mg, phos, ionized Ca, vitamin D, albumin, EKG for prolonged QT
- low= Mg (diarrhea, alohol, diuretic) will decrease PTH secretion
- Tx: if iv= er disease, then 24-vitamin D. If kidney disease, then 1,25 vitamin D= . Else just D3 is okay.= hypoglycemia
- if cpeptide high, possibly insulinoma or t= aking ora antidiabetic pills
- if cpeptide low, possibly insulin injecti= ons

Insulinoma:
- tsh, free t4, am cortisol
Sulfonyurea = and meglitinide screen and insulin ab (hypoglycemia panel)
- 72 fast tes= t is - when glucose <60, send c-peptide, pro insulin, insulin level, bet= a oh. Then until neurological symptoms or glucose <45 and re= send all labs. Then give them d50
- tx: diazoxide
- then if ct with c= ontrast imaging negative, do a EUS

Hypokalemia
- diuretic use or gitelman syndrom= e =3D high urine Cl
- laxatives =3D urine K will be low to hold onto K a= s much and get metabolic acidosis (HCO3 in stool); urine anion gap (U= rine Na + Urine K - Urine Cl) would be negative
- vomiting =3D urine pH = will be high and low urine Cl (to compensate for body losing H, will excret= e HCO3 in urine)

gitelman syndrome
- S&S: young adult/teen, w= ith low BP, low K, high CO3, high Ca
vs. Bartter sydnrome - presents as = child
hyponatr= emia
- Calculate rate: Sodium Correction Rate in= Hyponatremia and Hypernatremia - MDCalc
- causes: drugs (e.g. bactr= im a lot of times)
- physiology is ADH appropriately (hypovolemia or hyp= ervolemia with decreased effective arterial volume EAV (CHF,nephrotic syndr= ome, cirrhosis) or inappropriately increased; rare - primary polydipsia /te= a toast/beer/malnutrition (low solute) will decrease ADH =3D restrict fluid= and salt restriction
- correct for glucose every 100 over 100, add 2.4 = to Na
- if cirrhotic with ascites and <120, can trial albumin (increa= ses EAV)
- Urine Na <20 mEq/L =3D extrarenal loss i.e. kidney a= ble to absorb Na back (if hypovolemic: vomiting, diarrhea, third spacing; i= f hypervolemic: HF, cirrhosis, low alb) ; > 20 =3D renal issue ((t= hiazide)) diuretics, minerocorticoid deficiency; if hypervolemic: renal fai= lure)
- if euvoluemic =3D free water restrict and treat underlying
&n= bsp; - if Urine Osm > 100 mOsm/kg =3D SIADH (inappropriately high), <= 100 (i.e. ADH appropriately low) =3D primary polydipsia/beer poto. Os= m is surrogate for ADH.
- if hypervolemic - all fluid restrict + salt re= strict
- if acute (<48 hours), can correct quickly. If chronic and as= ymptomatic, increase 4-6 in 24 hours to prevent ODS (osmotic demyelination = syndrome)
- if severe, 3% NS 100cc bolus (careful extravasation risk of = skin necrosis) and then 0.5-2cc/kg/hr until symptoms resolve (need central = line?); can correct 6-8 in 24 hours

- can consider vasodilator in CH= F (ACEI/ARB)

SIADH
- causes: malignancy, lung (pneumonia/asthma/T= B), brain (trauma/stroke), drugs (SSRI, chemo, antipsychotic), post-op / na= usea / pain
- = Hypouricemia (uric acid < 4 mg/dL) is frequently observed in patients= with SIADH during the period of hyponatremia

NS has 154mEq/L Na=
LR has 130mEq/L Na, 4 K

- can add urea salt if salt tag 3g TID d= oesn't work due to sodium wasting (3g TID is 1 L NS without the water= )

If pseudohyponatremia, measure Na with VBG lytes as uses anode to = calculate

alcohol, BUN, glucose can increase serum osm that make= s water go into blood stream, and fakely decrease sodium

- pseudohyp= onatremia (isotonic 275-295: if high paraprotein ((e.g. multiple myel= oma, high trig) -- because sodium in lab is based on Na over plasma, not Na= over water

-= PE: JVP, mucous membrane
- orthostatic
- serum Osm, urine Na, urine = Osm
- TSH

# {Acute if less than 48 hours} {mild 130-134,= moderate 120-129, severe <120} Hyponatremia: Patient's serum sodium ***= on admission. Hyperglycemia {is/is not:9024} present and the corrected ser= um sodium is *** (add 2 meq/L for every 100 mg/dL above normal). Pseudohypo= natremia {is/is not:9024} suspected (patient is not jaundiced, no hx of pla= sma cell dyscrasia, not postoperative after prostate or uterine surgery, ha= s not received mannitol or IVIG) and patient's serum osmolality is {normal/= elevated:21542} at ***(>280). Patient's GFR is normal at *** (>= 90) and is *** not on a thiazide diuretic. Patient is currently {asymptomat= ic vs symptomatic} with *** {Seizures, Obtundation, Coma, Respiratory Arres= t, Vomiting, Fatigue, Lethargy, Confusion, Forgetfulness, Headache, Dizzine= ss, Gait disturbance, Nausea, Muscle cramps}

<= /div>

DIAGNOSTIC

Presentation is consistent with hypovolemic = hyponatremia: low BP / postural hypotension. And urine sodium *** urine oso= ms ***

INTRARENAL LOSSES

- r/o head injury (Cereb= ral salt wasting)

- review home meds (diuretic induced)

- consider AM cortisol and ACTH stimulation test (primary adrenal insuffic= iency if low cortisol and +ACTH stim test)

EXTRARENAL LOSSES

- GI loss, third space loss,

- UNa of 25-40 -- will a= dmin IVF and recheck

Presenta= tion is consistent with euvolemic hyponatremia.

Urine osmol= ality of *** (>100) with urine sodium of *** (>40) concerning for SIA= DH, hypothyroidism, or glucocorticoid df.

- f/u AM cortisol and A= CTH stim test (glucocorticoid df)

- f/u TSH

- if = both negative, consider SIADH.

Urine osmolality of *** (<= ;100) concerning for high fluid, low protein diet or self induced water int= oxication -- consider beer potomania, tea and toast diet, endurance event, = ecstacy use, psychosis.

Presentation is cons= istent with hypervolemic hyponatremia

Una *** (<10) and FENA *= ** (<1%) concerning for CHF, cirrhosis, and nephrosis

- = f/u BNP

Una *** (>20) and FENA *** (>1%) concerning for ren= al failure

TREATMENT: goal is to raise no more tha= n 6-8 meq/L in 24 hour

- Trend BMP {q4hr}

- IVF with no= rmal saline 1L over 1 hour and recheck (hyponatremic hypovolemia <130)&n= bsp;

- 50 mL bolus of 3% saline (pt asymptomatic w/ serum sodium = <130 and acute)

- 100 mL bolus of 3% saline followed by 100 mL= doses x 2 (symptomatic patients with Na<130 )

- ID and discon= tinue drugs that could be contributing to hyponatremia

- Li= mit further intake of water if with moderate hyponatremia (120-129) and mil= d to moderate symptoms.

- If severe hyponatremia (<120) initia= te 3% saline at 15-30 mL/hour. Consider desmopressin to prevent overly rapi= d correction in rapidly reversible conditions.

- Fluid rest= riction indicated for hyponatremia in edematous states (CHF, cirrhosis) or = SIADH, advanced renal impairment, or primary polydipsia.

- Can co= nsider loop diuretics (furosemide inhibits NaCL absorption-- causes ADH res= istance-- excretion of more dilute urine), salt tabs (avoid in CHF, cirrhos= is), urea, potassium supplementation, or vasopressin receptor antagonists (= vaptans).

hypopituitaism
- can be tranisen= t or permanent
- after traumatic brain injury, would recommend cortisol,= free T4. 3-6 months after - IGF1, cortisol, Free T4 and testosterone= and yearly for 3 years.Hypothyroid
- normal reflex bicep, then slow relaxation
- take= synthroid early in morning, wait, then eat breakfast (vitamin/mineral affe= ct absorptions, ppi)
- free t3 fastest to drop, tsh most stable
- if = severe hypothyroidism, test cortisol in case adrenal insufficiency
- tsh= > 10, always treat
- if going to be pregnant, treat
- subclinical= hypothyroidism: if 5-10, if antiTPO ab positive, consider trea

= non-thyroidal illness syndrome: when ill - Free T4 low or noaml. low = TSH when ill, high TSH when recovery phase. Test 4-8 weeks after agai= n
Treat subclinical hypothyroidism if TSH > 10, and symptomatic =
- synthroid: take on empty stomach 60minutes before breakfast/cof= fee. (take iron, PPI, and calcium before/after 4 hours else imp= acts absorption of synthroid)
- age <60, start at 100ug/d. >= 60, start at 50 ug/day, increase 25uq q6w until TSH 1.0-2.5; heart disease:= start 12.5-25ug/d

generic levothyroioxine may not work for ever= yone. Sometimes need to have brand name Synthroid

IBD-Ulcerative colitis flare= / Crohn

Ibd higher risk of skin cancers

#Acute Ulcerative Colitis Flare - Severe UC= (True-Love Witts, Montreal Criteria) E3S3 based on OSH pathology results.&= nbsp;

- Please ensure daily DVT ppx = as IBD patients are hypercoagulable given inflammatory state.

- E= ncourage routine ambulation

- Dietician consult

-= Please consult colorectal surgery for evaluation and education on potentia= l treatment options in the setting of IBD flare

- Order MR = enterography

- Obtain B12, folate, iron panel, ferritin

- Vitamin D level

- Please order "Prometheus IBD SGI= " as a miscellaneous send out lab to look for genetic markers of Crohn vs U= C

-IV steroids (methylprednisolone 40 mg q daily for 5 days=

- Ensure GI prophylaxis while on steroids

- 50k = vitamin D weekly

- 1000mg of Calcium daily while on steroid= s

- Please obtain daily CRP and ESR

-Consider standing tylenol as a base pain medications and dc all op= iates due to increased risk of toxic megacolon,

<= div>

- Please order tap water enema to be= given at 7 am, 8 am, and 1 tap water enema PRN and in comment "to be given= prior to departure to CDDC for procedure"

- Please obtain the following labs in preparation for biologic therapy= : TPMT, hepatitis C ab, Hepatitis B Ag, hepatitis B core antibody, Hepatiti= s surface antibody, HIV, VZV (quantitative PCR), fasting lipid panel, quant= iferon (please draw this PRIOR to steroid administration), EKG

<= div>

- If on steroids would place concurrent PPD -- please in= struct nurses to document it's results in MyChart.

Please obtain LFTs, daily CRP, ESR, iron studies, vitamin D &nb= sp;

IV methylprednisolone 40-60 mg daily x 3 days.= If no response after 3 days, will consider inpatient rescue therapy <= /div>

- Can consider discharge on 8/12 if patient does w= ell on oral steroids with steroid taper starting at 40 mg and dropping by 5= mg every 7 days. For ease of ordering:

-Type in "pre= dnisone" to orders. Input 40 mg for 7 days. At the bottom of the box click = "Link Order"

-Select "Followed by" "a copy of the new order= "

- In the following box, input 35 mg instead of 40 mg.&nbs= p;

- Repeat until off.

- Tra= nsfer this order to an outpatient order in your discharge medication reconc= iliatoin

Abdominal XR given patient's worsen= ing illness

- Please discontinue mesal= amine (can sometimes have paradoxical effect in setting of acute colitis)&n= bsp;

IBS

= - IBS-D: treat with eluxadoline (if normal, loperamide, TCA, rifaximi= n)
- IBS-C: treat with lubiprostone, plecanatide, or linaclotide if FODM= AP, miralax still doesn't work and PEGICH hemorrhage (brain bleed)
- don't use nitroglyc= erin or nitroprruside to lower BP as increases intracerebral presure
SAH
- nimodipine SBP goal 140-180
- consider TCDs
- neuro checks<= /td>ICU
- iNO; ne= ed daily morning carboxyhemoglobin and methemoglobinID infection work up: karius crazy work= upif cannot do P= EG, can do PTEG
<= /td>Iga nephropathy
- can get gross blood in urine, in setting of infec= tion or after heavy exertion
- just monitor, no steroids needed.ild bronchopulm thickenin= g, architectural changesILD interstitial
- Sx: clubbing, velcro- crackles
- causes: i= diopathic pulm fibrosis, acute inter, bronchiolitis from smoking, sarcoid, = amyloid, vasculitis, IVD, sclerodemra/poly/dermatomyositis, RA, inhalation,= hypersensitivity pneumonitis, drugs (nitrofurantoin, methotrexate, amio), = radiation
- Tx: acute prednisone 1mg/kg/d and broad spectrum Abx x7 days= Ileus

-Conservative management

-NPO for bowel rest

-NG tube and rectal tube for decompr= ession

-Serial KUB

-Avoid narcotics

-Increase= movement in bed, up to chair, or ambulate if possible.

-Re= plete electrolytes (K>4, Mg>2, Phos>3) at least daily

-C= onsider Relistor (methylnatrexone)

-Consider neostigmine if no im= provements with conservative therapy. Contraindications include bradycardia= , allergy,

immunizations
- prevnar: 65+, u= nless medical condition risk for pneumonia (alcoholism, liver/lung/renal di= sease, DM, cancer, HIV, sickle)
- still need shingrix (Recombinant) if p= reviously had live attenuated shingles (zostavax), 97% versus 50% effective= infection / seps= is
- score: qSOFA (Quick SOFA) Score for Sepsis - MDCalc (= mortality)
- classification:
- sepsis: 2+ SIRS (temp, RR>2= 0, HR > 90, WBC, PCO2<32)
- severe sepsis: SBP <90, MAP = < 65, Cr > 2, oliguria < 0.5cc/kg/hr, bili > 2, Plt <100k, I= NR>1.5, lactate >2
- septic shock: persistent hypotension a= fter 30cc/kg, lactate 4+
- anaerobes: zosyn (pieracillin-tazobactam), au= gmentin (amoxicillin-calvulanate), unasym (Ampcillin-sulbactam), all carbap= enems, clindamycin, flagyl, 2nd gens (cefoxitin, cefotetan),

- Sx: s= leepy, confused, RR>20, fever/cold, WBC, CRP >2 SD, sugar
- Tx: va= nc+ceftriaxone+/-azithro, or vanc+zosyn

- if staph bacteremia, need = echo to r/o infective endocarditis and repeat Bcx until negative, then 14 d= ays Abx from that

meropenem - for ESBL (PICC)

Zosyn= covers for enterococcus, ESBL Ecoli, and pseudomonas; ceftriaxone + flagyl= does not.
'
enterococcus - vancomycin also covers. But if VRE.= cipro can, but not as good; do augmentin instead (tests for it but n= ot reported, because they want to save cipro for other things); can also do= linezolid
- if positive, always just get CT with contrast to see source=

Antibiotics Abx Tx duration / infections

- abdominal= infection: 7 day (if = gram negative, study 7 versus 14 day trial 2 bugs, not hemodynamically stab= le, immunocompromised need; may only do for UTIs)

- C-diff= : 14 days

- bacteremia: 7 days (even for ESBL); follow IDSA guide= lines

- augmentin for human/dog/cat bite

- azithromycin= for pertussis (whooping cough)

- g= ram positives: after 24 hours, repeat Bcx

bactrim = - not as good for old people kidney

- enterobacter cloecae: cefepime is better than zosyn (per UCI pharmacy)

- enterococcus faec= alis sensitive to ampicillin (ampicillin + ceftriaxone for enterococc= al endocarditis)

- Marik protoc= ol: thiamine, hydrocortisone, vitamin C helps with severe sepsis?

!!! cefepime does not cover enterococcus; need zosyn (or im= ipenem)

candida and MRSA need AUTOMATIC consult

Klebisella consider opthalmitis

ceftriaxon= e creates biliary sludge

ceftriaxone - actually ha= s a little anaerobe coverage

levaquin - 60-70% eco= li coverage only, and poor staph

cefepime can caus= e confusion and lowers seizure threshold

for ampC resistance organisms: https://www.idsociety.org/practic= e-guideline/amr-guidance/

citrobacter, enterobacter, - if suspect= ible to CTX, still don't give -- give cefepime only; ampC resistance

<= div>

bactrim - if m= ore than 2 weeks, use CBC (Cr, K, CBC)

- 30mg/kg unless pulmonary edema in first 3 hours- lactate, repeat in 3 hours
- if >2, 30mg/kg and reassess, = then 20mg/kg if still >2
- ABG as needed for acidosis, hypoxemia, hyp= ercap
- procalcitonin
- D-dimer
- Bcx, UTI, CXR,
- glucos= e 140-180
If inflammation, ESR, CRP

3D"Antibiotics

insomnia
- chronic should try doxepin= , not trazodone
- chronic =3D functional distress, occurs 3+ nights/week= for 3+ months, and no other sleep/medical/mental disorder. CBT first= , then doxepin (a TCA)
- Zolpidem: There is potential for prolonged impa= ired driving skills, somnolence, and amnesia with their use, and there are = few data on the long-term safety or efficacy of these agents. Reports of se= rious or fatal injuries associated with complex sleep behaviors prompted th= e FDA to issue a boxed warning for zolpidem.insulin:
if glargine more than 25 units, give= BID is better for absoprtion as too much in 1 time big liquid
- if a1c > 10, inpatient, ensure oral + glargine at 75% - or stop= oral and continue inpatient basal+bolus
- add metformin typically to in= crease insulin sensitivityintegrative health
- lysine - prevent herpes
- glutam= ine - bowel
- curcumin/tumeric - anti-inflammation; tumeric - from = other countries can have lead (check Consumer Labs)

- LiverTox for d= ietary supplements
- green tea extract: 100 cases of liver injury (possi= bly due to HLA-B*35:01)
- natural medicines trc

- multivitamin, v= itamin C, D, calcium, Mg, CoQ10, fish oil, psyllium
- vitamin C 200 mg/d= aily for diabetes, smoking, copd to help support immune system
- vitamin= D3 better; > 100ng./mL is potential vitamin D toxicity

1-18: 120= 0 IU/day
vitamin D: pregnancy 2500 IU/day
high-risk prediabetes: 3500= IU/day
75+: lower risk of mortality

Low Mg: poor appetite, muscle= spasm, arrhythmia, fatigue

Mg: magnesium threonate good penetra= tion to nerves; magnesium citrate: binds to oxalate, good for those with ki= dney stones. magnesium oxide: most likely to cause diarrhea

ma= gnesium glycinate -- best ideally

Mgnesium: for migraine prevent= ion (migraine with aura and premenstraul migraine), preventing T2DM/lowerin= g fasting glucose. maybe for pain control too.

If taking PPI, = will get low Mg.

CoQ: also help with migraine prevention 3D""

interstitial cystitis (bladder pain syndrome)
- Sx: bladder pa= in with filling for 6+ weeks, no other causes, better with urinating
- T= x: behavior, amitrityplineIntubation:
- induction: ketamine 1.5 mg/kg IBW (onset 60-90s,= duration 10-20m), propofol 2mg/kg IBW (onset 30 seconds, duration 10 min)<= br>- paralytic: rocuronium 1.2mg/kg IV by IBW (onset 60 seconds) preferred = over succinylcholine 1.5mg/kg onset (cannot use in high K)

- for awa= ke inttubation, use ketamine - amnesia, dissociation, and analgeic, but sti= ll have respiratory drive. Also benefit increases BP and relaxes bronchial = muscle.
- if intubation fail if > 90% on mask ventilation, try again.= if <90, then cricothyrotomy.

- LBM: Fentanyl 5mcg/kg also , = versed

propofol can decrease BP; Versed less.

Weaning cri= teria
- HR < 130, RR < 35, BP < 180, SpO2 > 92% on FIO2 <= =3D40% or PO2/FiO2 >=3D170 if ABG, RASS -1, PEEP <=3D8, hemodynamic s= table

- RSBI =3D RR/Vt <105 breaths/min/L
- NIF <=3D = -20 (more negative good) -- negative inspiratory force

3D""

Intubation
ketamine first, can sti= ll see breathing, then roc
suc also used for paralytic; etomidate also f= or sedation
= I= ntubation
ketamine, precedex, fentanyl/versed
instead of prop fent as= prop gets them more RASSIT band syndrome
- pain at lateral knee, distal lateral thigh- test: Noble test: repeat flex and exten of knee with thumb over lateral = femoral condyl (no need imaging)
- Tx: ice, abstain from activity, massa= ge, slow gradual return to activity= ITP and rheum issues stress dose steroid
- 1mg/kg pre= dnisone (~300mg hydrocortisone/day stressful situation)

<= td spellcheck=3D"false" contenteditable=3D"true">JAK2 myeloproliferative= neoplasms
- jaundice
- if painless, CT, concern for cancerjehovah witness increase hgb
- Increase B12 PO to 2000 mcg/day (10/26-)

- Increase to folate = 4 mg/day supplementation

- Complete ferrlecit 250mg IVPB (10/26-)= for 4 days total

- Initiate Procrit 40,000 units weekly with goa= l of Hgb 12.0

- Minimize blood draws and use pediatric tube= when possible

= joint fluid
- WBC <200 =3D normal, <2k =3D oste= oarthritis, 2k-20k =3D inflammatory; 10k-50k =3D crystal; <75k =3D gout/= RA; >50k =3D infectious; >100k =3D septic arthritis
Kidney stone / nephrolithiasis<= br>- 2L+ water
- limit animal protein as sulfuric acid =3D causes calciu= m release
Urine more basic so

- cystinuria - tiopronin
<= br>- if prescribe bactrim, drink a lot of water, else will get wheat-lookin= g stones

#Nephro= lithiasis

Most likely calcium oxalate. RF include male gender, in= creased age, white race, obesity, diabetes mellitus, the metabolic syndrome= , decreased fluid intake, chronic diarrheal states, and Roux-en-Y gastric b= ypass. Patient fits typical presentation is waxing and waning =E2=80=9Ccoli= cky=E2=80=9D flank pain that radiates to the groin. Ddx includes ureteral p= assage of blood clots which can mimic renal colic pain. 50% of stones >6= mm will pass, stones >10 mm unlikley to pass.

- Urinalys= is

- Noncontrast helical CT is gold standard

- Kidney ultrasound since no radiation exposure.

- Vitami= n D level -- excess vitamin D intake can precipitate calcium oxalate stones= .

- Counsel on decreased dietary oxalate (avoid nuts, cocoa= , spinach, rhubarb, beets) and low sodium intake (lowers urine calcium)

- DC orlistat with is associated with hyperoxaluria

= - Increase fluids -- normal saline @ 150 mL/hr if tolerated

- Decreased sodium intake

- Thiazide diuretics

-= Potassium citrate or bicarbonate

- Pain mgmt with opioids = PRN

- Allopurinol if concern for elevated uric acid

- Tamsulosin 0.4mg PO QD (hold for SBP < 90) (ureteral relaxati= on for spontaneous passage)

- Urologic intervention required if s= igns of infection, acute kidney injury, intractable nausea or pain, and sto= nes that faill to pass -- urology consult to consider shock wave lithotrips= y vs ureteroscopy with laser ablation vs percutaneous nephrolithotomy. = ;

- 24 hour urine measurement outpatient if recurrent stone forma= tion

- If hypercalciuria present -- consider thiazide use t= o decrease calcium excretion

- Potassium citrate to prevent= calcium crystal formation (low urine levels associated with increased ston= e formation)

- If elevated urine pH =3D calcium phosphate -= - predisposed if hyperparathyroid, acetazolamide, or topiramate (raises uri= ne pH and decreased citrate excretion)

<= td spellcheck=3D"false" contenteditable=3D"true" class=3D"sorting_1">kidney= transplan:
- if septic, don't hold prednisone or tacrolimus, only hold = myfortic/cellcept
- transplant pt: bicarb, mg, and phos wast= ing normal, need replete (Bicarb > 22)

myfortic - better th= an cell cept as coated and does not cause diarrhea as muchif on tacrolimus, daily tacrolimus le= vel

Klebsisella
- hyperviscous klebsiella likes to cause absc= essesknee
patellofemoral pain syndrome
- pain going down the stairs, female, runn= er
- PE: pain with flexion of knee/squatting (91% sensitive pain with sq= uatting)
- Tx: cyrotherapy in acute phase; then PT

pes anserine p= ain syndrome
- pain at anteromedial knee 6cm below joint line

pre= patellar bursitis
- Dx: need to aspirate. If >50k/uL leukocyste= , septic brusitis= KUb
- cecum 9
- colon 6
- small bowel 3 to confirm SBO
Long QT syndrome
- ri= sk of Torsades
- If congenital Tx: beta blocker. ICD if previous cardiac= arrest

QTc
- ciprofloxacin/macrolides (also not if AAA) - al= so causes tendon rupture
- little: atarax (hydroxyzine), antiemetics
= - antipsychotics/antidepressants
- antifungal
- antiarrhythmics
= =3D methadone

- if prolonged QT, stop drugs that cause bradycardia, = K >4, Mg > 2.5 (K>4.5-5 who has torsades)

vs = brugada syndrome
- risk of sudden death
- incomplete RBBB with ST ele= vation in V1 and V2

low testosterone
- 2 x 8am total testosterone; 2nd time measur= e free testosterone toolung nodule
- if > 8mm: repeat CT at 3 months; if high risk (a= ge, smoking), consider biopsy; 6-8mm - CT at 6-2 months

- 3cm likely= cancer.malnutrit= ion

#concern for= severe protein malnutrition: Wellcamb classification *** mild (albumin 2.8= -3.4), moderate (2.1-2.7), severe (<2.1). Transferrin mild (150-200), mo= derate (100-149), severe (<100). Total lymphocyte count mild (1200- 2000= ) moderate (800-1199), severe (<800).

- Prealbumin =

- Nutrition consult

- Boost daily

mania (psychotic)

acute mania (high energy, no= need for sleep, grandios)
- Tx: with antipsychotic first --- risperido= ne have quick onset
- DO NOT give antidepressants in manic patient,= will worsen mania.<= /td>Mds
- linalidomide if symptomatic and have del5qtp53 tp53 mutation = =3D poor prognosis
medication allergy:
- always order tryptase to any allergy

= anaphylaxis to
- penicillin: can still give cefazolin, ceftriaxone, cefp= oroxime, and cefepime without testing (non-cross-reactive cephalosporin). D= o NOT give cephalexin without testing (cross-reactive). Can give carb= apenems
- cephalosporin: need testing to give penicillin. Can give= carbapenem.
- carbapenem: can give cephalosporin or penicillin without = testing.
If SJS to one penicillin/cephalosporin/penem, do not give any t= he others.MEN1- SS: hyperparathyroid, pituitary tumor, and pancreatic tumor (e.g. gastri= noma, ulcer disease, insulinoma)MEN1: hyperparathyroidism, pituitary tumor, pancreatic/gast= rin/VIPoma/some abdoinal tumor
MEN2: hyperparathyroidm, medullary thyroi= d cancer, pheochromocytomameningioma
- benign tumor outside brain tissue
- if asymptom= atic, just do serial brain MRI monitor
- if symptoms, then removemeniscal tear
- if d= egenerative meniscal tear (in older people), just PT, no need MRI or imagin= g
- test: McMurray (external reotate tibia) or Thessaly test (stand and = turn body)

ACL
- isolated partial ACL tear, non-operative is best= over surgerymeta= bolic alkalosis (pH > 7.45 and HCO3 > 24)
- test for urine Cl
&= nbsp; - if <20mEq/L, vomiting/diuretic overuse =3D will respond to NS - if > 20 mEq/L =3D NS will not work
- hypovole= mic =3D Bartter/Gitelman syndrome
- hypervolemic =3D high = mineralocorticoid (primary hyperaldo, cushing, ectopic ACTH production)metabolic alkalosis=
- DDx: vomiting, loop/thiazide, Cushing, too much NSmetformin:
- not for GFR < 30&= nbsp; (risk of acidosis)
- need B12 supplement as decreases absorption&n= bsp;
- need annual B12 level testing if on metformin
- si= gns of B12 deficiency (loss of vibratory sense in toes, patellar, and achil= les reflex)
= M= GH
GRP-UCI IM Residency - MGH Whitebook 2021-202= 2 - Undedited.pdf (sharepoint.com)
microscopy
- compare size of lymphocyte nucleus= to RBC to see if RBC is small or large or normal
- monocyte has vacuole= s
- hypersegmented neutrophil (more than 5 lobes) =3D megaloblastic anem= ia Ddx: folate or B12 deficiency, drug affecting folate metbolism. 3D""

midline
- smalle= r - for inpatient use (not for drawing blood?)
- should not do PPN if &g= t;600 or >900 osmol

PICC
- longer, for take home

periph= eral IVs should be changed in 1 weekmorbilliform rash

# Morbilliform eruption, favor drug > viral= - uncomplicated

- We favor a morbilliform rash, in the setting of= drug > viral illness. We favor this diagnosis, opposed to a more compli= cated drug rash such as small vessel vasculitis because there is no palpabl= e purpura (I.e. all lesions are flat). There are also no lab abnormalities = (elevated liver enzymes or Cr), lymphadenopathy, or facial swelling to sugg= est DRESS. Additionally, there is no epidermal detachment nor mucosal, geni= tal, or ophthalmologic involvement to suggest SJS/TEN.

- Th= ese types of uncomplicated morbilliform eruptions usually occur 5- 14 days = after medication initiation. It is likely that this rash is secondary to a = medication that was given during his recent prior inpatient stay. The most = common causes are: antibiotics, NSAIDs, opioids, and diuretics (such as fur= osemide).

- Reviewed chart and previous MAR (from prior adm= ission). During stay, patient was started on NORCO. This is a likely agent = to cause the rash. No NSAIDS or antibiotics were given. Home furosemi= de was discontinued. Due to the timeline, with NORCO being given on 2/11, t= his is the favored cause; however, unable to definitely say.

- Despite this rash occurring 2/2 to a presumed medication, the patient c= an continue his medications if needed.

- ~80% of morbillifo= rm drug eruptions resolve within 2 weeks. It is not painful or pruritic so = no further treatment is necessary at this time.

MRSA risk fa= ctors
- MRSA or prior infection, gram+ cocci in clusters, recent IV abx = use in 3 months, flu-like illness, empyema, immunosuppression, ESRD, prison= , IV drug use, men sex with men, recent head injury, chronic hemodialysis, = recent flu

Tx: vanc, linezolid, daptomycin, tigecycline, ceftaroline=
oral: bactrim, clindamycin, doxycycline

clindamycin sensi= tive by eryto resistent then don't use clinda
- vanc MIC > 2, not goo= d (curbside ID)= my= elodysplastic syndrome (anemia)
- Tx: supportive care and transfusions/E= PO
- Tx: if young and symptomatic, stem cell transplantmyoclonus: fast twitching, but no= t suppressible
tic: childhood onset, fast twitching, but suppressiblenaproxen vs ibuprof= en
(naproxen least complications with heart)

meloxicam good for m= enstrual cramps= n= arcolepsy
- modafinil (also used if hypersomnia or severe cancer-related= fatigue)nausea /= vomiting
- in advanced cancer, olanzapine can help (also used in refrac= tory depression, but together with another med)
- UCI palliative Dr. Nis= co seems to like compazine 5mg PO q6h - if works for doamine blocker IV hal= dol (dopamine blocker) 5mg IM
if QTc allows

cannabinoid marijuana= vomiting/hyperemesis syndrome
- Zofran, fosaprepitant. haldol IM = also works

vomiting
- zofran 8mg q8h PO or 4mg IV q8h
- promet= hazine (Phenergan)
- prochlorperazine (Compazine)
- metoclopramide (R= eglan)

(if caused by opioid, chemo, toxin, or drugs, - target GI= tract or chemoreceptor trigger zone =3D antidopamine good =3D compazine, p= henergan, haldol, metoclopramide, chlorpromazine, olanzapine -- SE: sedatio= n, hypotension, dystonia, pseudoparkinson)

- can also try Haldol if = really bad

- if QTC
- scopalamine patch but useless
- z= ofran or promethazine x1
- Tigan trimethobenzamide (200 q8h PRN)
- Em= end IV (antihistamine for chemo - restricted) or dexamethasone (also che= mo premed) or benadryl

if due to constipation/gut wall/i= leus =3D D2 receptor (metoclopramide, prochlorperazine, haldol, olanzapine)=
if gut mucosal injury (infection, inflammation, tumor, chemo, radiation= ) =3D serotonin receptor in gut (zofran)
if drugs or bacteria, D2 5HT, N= K1 all okay =3D NK1 blocker (aprepitant)
motion sickness or ear =3D H1 r= eceptor (scopolamine, diphenyhydramine, promethazine)
anticipatory nause= a =3D benzo and olanzapine
- if due to ICP =3D steroids help

Ongoing abdominal p= ain meets Rome IV criteria for cyclic vomiting syndrome -- patient endorses= chronic migraine history, episodic vomiting with period of normalcy in bet= ween episodes. Episodes are often associated with headaches and autonomic s= ymptoms such as diaphoresis. Patient also endorses relief with hot baths. O= ther ddx include malabsorption given atrophic pancreatitis on CTAP and hist= ory of recurrent pancreatitis.

#Epis= odic nausea and vomiting

#Cyclic vomiting syndrome: as this= is a diagnosis of exclusion, will need to rule out other etiologies such a= s gastroparesis and biliary dyskinesia

- Gastric emptying s= tudy as an outpatient to rule out gastroparesis

- Please order CC= K HIDA as an outpatient to rule out biliary dyskinesia

- Start Co= q 200 mg BID Check levels within 2 weeks outpatient and titrate to goal of = 3-4 (please see follow up instructions)

- Please order coq = enzyme level for outpatient follow up in 2 weeks at discharge (goal level i= s 3-4)

- Start L-carnitine 1g BID, or patient can purchase OTC&nb= sp;

- Please order carnitine level in 2 weeks at discharge (goal = suggested target blood level is a free carnitine level >40 micromol/L)

- E-consult to Neurology for optimization of migraine meds (non-or= al triptans bring relief for nausea, characteristic of CVS)

- Start nortriptyline 10 mg qHS for MAINTENANCE against CVS.

- Please prescribe sumatriptan intranasal dose 20 mg on discharge -- thi= s is to be used for an ABORTIVE when patient feels an episode coming on. Ca= n repeat dose in 2 hours if needed.

- Ensure adequate volume resu= scitation as one of the triggers for nausea can be dehydration-- 1L NS bolu= s now then maintenance rate with D5 1/2 NS, 60 cc/hr + 1ml/kg/hr for every = kg above 20 kg (ex: 60 kg adult =3D 100 cc/hr ) please adjust based on clin= ical status, cardiac and renal comorbidities, etc.

- Measur= e fecal elastase -- start Creon (at least 36k TID) if low

-= Continue PPI once daily for reflux symptoms -- please discharge on lansopr= azole 30 mg once daily.

- Phenergine supposi= tory

- Cyproheptadine

- Riboflavin

<= tr class=3D"even">neck

cervical myelopathy =3D by cervical spondylosis<= br>- test: MRI
- Tx: surgical decompression
Sx: lower motor weaness i= n arms/hands (less reflex), upper motor symptoms in legs (more muscle tone,= hyperreclex, clonus, babinski)
Lhermitte sign - electric shock from nec= k to spine with forward flex neck

vs. cervical radiculopathy=3D spin= al root compression from disc herniation or degenerative spine
- Sx: con= stant neck pain to arm and paresthesia in dermatome, decreased deep denton = reflex
- test: positive spurling test (put pressure down on head while n= eck bent to affected side and extended; pain better when lifting arm above = head)
- Tx: neck exercise + topical and oral NSAID, no MRI needed.
- = Tx: if motor weakness, then need surgery

neurogenic thoracic outlet = syndrome
- compression nerve root brachial plexus
- thin, young activ= e female with repetitive overhead stress
- Sx: numb, pain, of 1 arm arm,= neck, shoulder when arm overhead
- EMG normal
- Tx: physical therapy= for posture and strentening shoulder girdleneed dialysis
uremia with BUN > 100 - give= DDAVP to prevent uremic bleeding before quinton as need double dilation&nb= sp;nephrotic syn= drome

etiology of nephrotic range proteinur= ia most likely 2/2 uncontrolled DM2. NO indications for renal bx or steroid= s for now. At present, recommend to obtain following

- SPEP w IFE<= /div>

-UPEP w IFE

-Serum kappa and lambda free light chains

-Kappa lambda ratio

-PLA2= R

- ana, anca, complements were = unremarkable

- anti proteinuric measur= es including losartan

= nerves
common fibular
- sensation: lateral leg=
- dorsiflex (i.e. if common fibular nerve injury, will get = foot drop)

tibila nerve
- sensation: bottom of feet
- motor: p= lantarflex<= td spellcheck=3D"false" contenteditable=3D"true" class=3D"sorting_1">neurol= eptic malignant syndrome
- S&S: muscle rigidity, AMS, high temp, tac= hy/HTN/sweating.
- cause: antipsychotics (haldol), reglan, withdrawal of= carbidopa-levadopa<= /td>neuropenic fever / fever unknown origin
MASCC risk index

#SIRS: (2+) Temp > 100.4= or <95 // RR> 20 or PAco2 <32 // HR>90 // WBC > 12k or <= 4k or bandemia >10%

#Sepsis: SIRS + microbial source&nb= sp;

#Severe Sepsis: Sepsis with >1 organ system dysfunction (h= ypotension, AMS, acidosis, oliguria, ARDS)

#Septic shock: S= evere sepsis with hypotension unresponsive to fluid resuscitation (30c/kg b= olus)

#MODS: >1 organ system requiring interventional ho= meostasis

#Febrile neutropeni= a: MASCC Risk Index Score: Most often can be attributed to 60% GPCs, 40% GN= Rs. Given mucositis, high concern for GPC (CoNS) but cannot rule out fungal= infections. Evaluate for catheter associated infection

- B= lood cultures x 2

- UA / UCx

- Sputum Cx

- Viral panel

- CMV PCR

- Diarrhea: Stool= culture, O+P, C. Diff, CT A/P as neutropenic patients may not have abdomin= al pain

- Pulm symptoms: Flu/ RSV PCR, CXR/ CT CHEST, Bronc= h

- HA pain / sinus pain: CT face / sinus

- Fungal markers: LDH, beta d glucan, galactomannan if high irsk for a= spergillus (SCT, GVHD, neutropenia > 10-14 d)

- F/U cocc= i antibody, histo urine antigen and serum antigen, quantiferon with AFB x 3= , crypto antigen

Fungal culture sputum

- Cefepime or pi= p/tazo or meropenem for gram negative coverage within 60 minutes of present= ation.

- If low risk can use cipro PO + clinda vs clinda (P= CN allergy)

- Defer Vanc until documentation of a resistant GPC (= https://www.ncbi.nlm.nih.gov/pubmed/15722392)

- Fungal conc= ern: Micafungin or amphotericin

If resolutio= n of fever and culture negative, continue empiric treatment until ANC > = 500 and narrow to FQ ppx if afebrile x 4-5 days

<= div>If resolution of fever and source of infection -- tailor antibiotics an= d treat for recommended course then switch to FQ ppx until ANC > 500&nbs= p;

If fever continues for >4-7 days consider en= graftment, GVHD, TLS, drug fever, thrombophlebitis, hematoma, hepatosplenic= candidiasis

If clinically worsening, broade= n antibiotics +/- fungal cultures if worsening and obtain CT chest +/- bron= ch for fungal infections

- Bactrim ppx recom= mended for equivalent of >20 mg prednisone daily for >1 month and all= o/auto SCT.

- G-CSF recommended if high risk febrile neutro= penia -- though this shortens duration of F+N it does NOT decrease mortalit= y

#Fever of unknown origin: most likely infe= ctions vs cancer vs rheumatologic vs medications. Assessed for dental carie= s/ thrush, sinus tenderness, temporal arteries, thyromegaly, abdominal tend= erness, CV murmur, LN, skin, nails, rectal. If extensive work up is negativ= e, prognosis is good and most cases defervctions, followed by bacterial inf= ections vs GVHD vs viral. Central fever is possible esce. In the setting of= neutropenia there is high concern for fungal infein setting of SAH, intrav= entricular bleed, brain tumors. Drug fever is a diagnosis of exclusion and = can take 2-3 days post cessation to resolve-- often associated with morbili= form rash, LFTs, and eosinophils. Chemo can be associated with drug fever. = VTE can be associated with low grade fever.

Dental hx:

Immunocompromise:

Travel:

Blood product tra= nsfusions: Sick contacts: Sexual history:

Illicits:

Occupation:

TB:

Valve disorders:

Rec= ent procedure / hospitalization

- Avoid empiric an= tibiotics (unless immunocompromisd or HDUS)

- CBC w/ diff

- ESR

- ESR can be falsely elevated in ESRD

- Make sure to correct for age. Age / 2 for males and Age / 2 + = 10 for females.

- CRP

More acutely rises=

Falsely low in cirrhosis

- Proca= l

- HIV, RPR, LDH, TFTs, SPEP/SFL/UFL, ANA, ANCA, RF, CCP, = CRYO, EBV, CK, CMV PCR, ferritin, blood smear, HBV, HCV

- CT A/P = with contrast, CT Chest with contrast, CT head with contrast

- UA= / UCX

- BCx x 3 at different sites

- CXR

Infectious causes related to lines: lines present *= **

Infectious causes unrelated to lines:

- = Abdominal ultrasound to rule out acalculous cholecystitis

-= C. Diff in setting of antibiotic use

- Evaluate for joint = infection

- Meningitis

- Skin infections&nb= sp;

Noninfectious causes

- Drug fe= ver

- Uric acid for possible gout flare

- L= ipase for pancreatitis

- D-dimer / wells for DVT / PE =

neutropenic fever
- 2 sets bcx
- treat empir= ically with antibiotics (zosyn), no vanc needed (add linezolid/daptom= cin for suspected vancomyin resistant enterococci)
- if still fever in 7= days, add antifungal therapy (amphoB/itraconazole)
- CT and lab for ang= ioinvasive aspergillusnodules - fungal, norcardia (in immunosuppressed)

ground glass = - pulmonary edema, atypical pneumonia (mycoplasma, legionella) - anything -= ILD, blood= nsaid=
- no NSAID in CAD/CHFnutrition deficiency

Zinc:
- Sx: alopecia, hypogonad, ras= h around mouth and extremities, slow wound healing, bald, tase change, smal= l testes

Copper:
- brittle hair and change in skin color

B= 3:
- people who eat corn
- diarrhea, sun area dermatitis, dement= ia/depressionOHS= obesity
- decrease oxygen to decrease hgb affinity to oxygen, so it can= carry more CO2 away (haldane effect)OHS
- daytime pCO@ > 45mmold people with hyponatremia - quinine a= lso helps
running and cramping - can give tonic water (quinine)onchomycosis

- ple= ase check in to lab after this visit and obtain liver labs before starting = terbinafine

- if you have right upper abdominal pain, changes in = smell or taste, or skin rash, stop using

opioid use:
Adrenal insufficiency
- cau= ses secondary adrenal insufficiency - gets hyponatremia without hyperkalemi= a (supresses hypothalamic pituitary adrenal axis, but no diret effect on ad= renal cortex
- Dx: AM cortisol and ACTHopioid withdrawal
- COWS (order set)buprenorphine

S= tarting buprenorphine

- Give buprenorphine 8mg, 8 hours after las= t dose of opioids or when COWS >8 (plan for induction at 0800)

- Give a second dose of buprenorphine 4mg, 4 hours after the first dose

- Give a third dose of buprenorphine 4mg, 4 hours after the second = dose for a total dose of 16mg on day 1

- Start 16mg once daily th= e following day

- Pt will benefit from split dosing due to increa= sed analgesic effect compared to once daily dosing, thus recommend continui= ng 8mg bid while inpatient

- Will continue to work with our subst= ance use navigator Tiffany Hwang (714) 719-2925 to assist with discharge pl= anning

- Please notify me in advance of planned discharge

- PLEASE CALL prior to any anticipated procedures where buprenorphine ma= y need to be held or adjusted

If precipitated withdrawal occurs, please provide the following to pat= ient at the discretion of primary team:

-H= ydroxyzine 50-100mg PO Q6h prn anxiety/restlessness

-Trazod= one 50-150mg PO QHS PRN insomnia

-Loperamide 2-4mg PO Q4 PR= N diarrhea

-Ondansetron 4-8mg PO PRN nausea/vomiting <= /div>

-Methocarbamol 500-750mg PO Q8h PRN muscle cramping

-Acetominophen or nsaids (if safe to do so) for myalgias, HA

<= br>

<= tr class=3D"even">opioids
- don't use morphine in kidney or liver failure- fentanyl safest in kidney or liver failure; start lower patch if liver = failure (fentanyl only to be used in opioid tolerant patients)

- oxy= codone and hydromorphine decrease dose in liver failure/; oxy variable onse= t in liver failure
palliative care: avoid codeine and tramadol (Tramadol= has ddi with sertonergic meds)

- TCA or SNRI (venlafaxine or duloxe= tine) or gabapentin/pregabalin, carbamazepine to neuropathic pain

- = need stimuylant bowel regimen: senna, (can also add on osmotic- PEG/l= actulose/sorbitol) , or metylnatrexoneoral contraceptive OCP
- no combination if uncontro= lled HTN. breast CA, clot, liver disease, or migraine with aura
- no est= rogen if smoking > 15 cigarettes/day<= /td>Orthostasis
Abd binder, compression stocking, inc= rease salt intake
- 1st midodrine if not hfref
2nd fludrocortisoneosteomyelitis
- = tests: CRP 8+mg/dL and ESR 60+ favors this dx
- hold antibiotics until s= ymptoms/septic to increase yield
- Tx duration: need 6 weeks as takes th= at long for bone remodel

- now, PO showing non-inferior to IV (Bactr= im okay)
- if bone hardware, need Rifampin for film. (Start after source= control / hardware cleaned)

- if can probe to bone, 90% PPV for ost= eo, if cannot probe to bone, only 60% NPV, so still need MRI w con
- if = cannot MRI, then CT with contrast, if CT cannot due to metal hardware, then= tagged leukocyte scan and/or/or combined with three-phase bone scan.

#concern for = osteomyelitis: patient with dull pain, local warmth/erythema/ swelling , sy= stemic sxs. RF include ulcer area > 2 (LR 7.2), probe to bone test (LR 6= .4), ESR > 70 (LR 11), abnormal plain xray (LR>2.3), MRI c/w osteo (L= R 3.8). Probe bone is sufficient for dx in patients with DM (83% specificit= y 90% PPV). Thrombocytosis is also shown to be associated with osteomyeliti= s.

- MRI

- Bl= ood cultures x 2

- ESR/CRP

- CBC -- if leukocytos= is more indicative of acute vs chronic

- PPD/IGRA in patien= ts with risk of TB

- Brucella serology if at risk

- Plain XR first

- Would obtain MRI if negative = ;

- If MRI not possible due to GFR, can get a CT vs radionuclide = bone scan (false positive if soft tissue inflamation) if hardware is limiti= ng factor

- Bone biopsy is gold standard diagnostic test, but unl= ikely to obtain at UCI

- If able to obtain with ortho vs = IR can send for bone culture

- Obtain ABI to evaluat= e for possible vascular interventions to optimize blood flow to the limb&nb= sp;

- ID consult to add rifampin if hardware and s= taph

- Home health order in preparation for 4-6 weeks of an= tibiotics

- Consider PO antibiotics as oral antibiotics are non-i= nferior to IV antibiotics for 6 weeks of osteomyelitis treatment for certai= n patients (OVIVIA trial https://www.nejm.org/doi/full/10.1056/NEJMoa171092= 6)

- Surgical consult given failure to respond to medical t= herapies, chronic osteo, pyogenic vertebral osteo, or infected prosthesis.&= nbsp;

- Surgical consult for hyperbaric O2.

<= /div>

- Empiric treatment is usually vancomycin plus GNR coverage but w= ill delay antibiotics given patient is hemodynamically stable, has no neuro= logic compromise

- Will opt for vanc + cefazolin -2g IV q8 hours = for MSSA coverage

- Opt for vanc + cefepime for 2g q 8 hour= s or pseudomonal coverage

- Ortho if debridement&n= bsp;

- Neurosurgery if vertebral osteo with possible CNS extensio= n

- IR for abscess drainage

- Wound nurse c= onsult

osteoporosis
- any compression frac= ture =3D osteoporosis =3D start bisphosphonate
- calculate 10 yr fractur= e ris. if hip fracture >=3D3% or all fracture >20%, start bisphosphon= ate
- T score <=3D-2.5
- need calcium 1200+mg/day and vitamin D 80= 0+ units/day in diet + supplement
- if starting bisphosphonate, test vit= amin D and calcium level.

- no bisphosphonate if GFR < 30
- pr= olia subQ q6m. Need BMP and dental clearance

- denosumab in CK= D4 pts.
Also can do IV zoledronic acid infusion 1/year
- CAnnot give = IV biosphosphonate with low Ca and CKD
- repeat DEXA in 2 years
thyroid medications can cause osteoporosis

- PTH

outpt
- annual low d= ose lung CT for 20+ py smoking hx and quit < 15 yrs ago, unti 80 yrs old=
- HPV/cervical cancer screening discontinue at 65 if 2 negative tests i= n past 10 yrs (most recent must be 5 years), else still test. HPV tes= ting (+/- cytology) every 5 years.from 25+.PAD (peripheral artery disease)
- ABI 0.9 or = below =3D bad

ABI =3D highest in both leg / highest SBP in both arm; lie flat for 5 minutes first)

0.8-0.9 - trea= t risk factors

0.8 or below, = refer to vascular

- need high statin, aspirin

- cilostazole (PDE3 inhibitor) for symptom relief. start = only if exercise fails (at least 30 min walk, 3 times week, for 3 months; keep walking increase until = pain longer to come) -- DO NOT give in HF pt

PAD
- Sx: exertional pain distal to occlusion
= - PE: decreased cap refill, decreased hair growth, sensation, get DP and PT= pulses
- CTA with run off if considering revascularization
- can add= cilostazol 100mg BID (dilates arteries) as adjunct to increase exercise ca= pacity; do not give in HF

Acute limb ischemia 6Ps: pain, pale, cold,= no pulse, no light touch
- emergent vascular consult

varicose veins

- Tx: leg elevation, compression = stockings

-= Tx: sclerotherapy injection if worsening veins after 6 months

PAD
- normal resting AB= I is between 1.00 and 1.40
- ABI of 0.90 or less is diagnostic for PAD- resting ABI greater than 1.40 indicates the presence of noncompressible= , calcified arteries in the lower extremities and is considered uninterpret= able. This is most commonly found in patients with diabetes mellitus and/or= advanced chronic kidney disease
- In patients with an ABI greater than = 1.40, a toe-brachial index is used for diagnosis. A toe-brachial index less= than 0.70 is diagnostic for PADpad
2.5 xarelto +aspirinpancreatic insufficiency:
- test for fecal ela= stase, if low, give creonpao2 65. If huge changes than spo2, then think about CO and = methemoglobinemia

- co-oximeter serum test can break down

- n= on-rebreather: 10L or 15L 2 settings only.parkinson
- carbadopa levadopa first; if still = not controlled, then add dopamine agonist (pramipexole, ropinirole)PCN infection - need to = be 6 weeks, treat through, then exchange= pericarditis
- Sx: CP better when leaning forward= and upright; worse when supine
- PE: friction rub at left sterna= l, best at end expiration leaning forward
- EKG: diffuse upsloping ST el= evation (PR elevation in aVR)
- causes: infection, viral, = autoimmune (vasculitis), breast, lung malingnant, drugs (hydral, procainami= de)
- Tx: NSAID 800mg TID (for 2 weeks) + colchicine 0.6mg BID (for 3 mo= nths). If doesn't work, after 7 days, prednisone 0.5mg/kg/d (for 2 we= eks)- EKG, bedside e= cho for effusion (drain if > 2cm)
- cardiac MRI if uncertain (very se= nsitive)pheochromocytoma
- HTN <20 yrs old
- look for MEN2, vo= n hippel-linday, and NF1
- need abdomen CT with con
- !!! give alpha = blocker before beta blocker
- use phenoxybenzamine efore surgery. = use nitroprusside or phentolamine for HTN crisispituitary deficiency
- ACTH deficiency:= weight loss, vomiting, abd pain
- TSH deficiency: cold weight gain, con= stipation
- visual field bitemporal (outside field blocked): mass effect=
- FSH/LH deficiency: ammenorrhea
- GH deficiency: loss of muscle mas= s

posterior pituitary:
- ADH deficiency: diabetes insipidus- thir= sty, polyuria/nocturia

Dx: 8 AM ACTH, cotisol, LH/FSH (only if n= o menstrual cycle), 8AM testosterone for male, estradol for female, TSH, Fr= ee T4, IGF-1
confirmation test: ACTH stim test and dedicated pituitary M= RI
Tx: need daily cortisol and thyroixine. Possibly estrogen for premeno= pause women and androgen for men if hypogonad.

hyperprolac= tin
- Dx: test prolactin, bHCG. If negative, test TSH to rule out = hypothyroidism causing hyperprolactin. Then MRI pituitary

pitu= itary adenoma:
- Dx: pituitary MRI, test for hypersecretion (prolactin a= nd IGF-1; FSH, LH, cortisol, TSH, T4, total Testosterone in men)
- = too much prolactin negative feedback to hypothalamus to decrease GnRH, whic= h decreases FSH/LH

any incidental pituitary mass
- test: am c= ortisol, TSH, Free T4, prolactin, and insulin-like growth factor 1, FSH, an= d LH for both sex (if normal periods, no need FSH/LH for female)

Tx:= for prolactinoma, give cabergoline (dopamine agonist to block prolactin);&= nbsp; if adenoma types that secrete other homones, surgeryPJP ppx
- bacrim

Bal if= concern
Tx if severe iv bactrim + steroids for A-a >=3D35mmhg or pO2= <70
When immunocompromised and then give Zarxio - immune system back = and fight against pjp - will get symptomsPlavix better (more potent) but do aspirin if any g= i bleedspleural = fluid
- CSF WBC/RBC <1/100 =3D 100% not meningitis
- adenosine dea= minase - for TB (but if positive in US may be false)

- fluid protein= /serum protein >0.5, LDH > 200 or 2/3 ULN, or LDH/serumLDH > 0.6 = =3D exudative
- if patient diuresing, serum to pleural albumin > 1.2g= /dL =3D transudate

WBC > 50k /uL or pH < 7.2 =3D complicated p= arapneumonic effusion/empyema
lymphocytes >80% =3D TB, lymphoma= , sarcoid, cancer
- triclyeride > 110 mg/dL =3D surgery trauma to tho= racic duct, lymphoma, or TB

= Pleural studies
Lights criteria
If triglyceride 50-= 110, then need chylomicron. If >110 =3D chylothorax

If chylothora= x, find cause. If not high output (<1L/day) then high carb, high protein= , low fat diet

<= br>

<= tr class=3D"even">pneumonia
- score: CURB-65 Score for Pneumonia Sev= erity - MDCalc;
PSI/PORT Score: Pneumonia Severity Index= for CAP (mdcalc.com)

- test urine legionella. patient who= exposed to kid attending daycare, think =CE=B2-lactam resistant strep pneu= mo
- post viral, most common strep, cavity would be staph aureus
- CA= P:
- Tx: ceftriaxone (+ azithromycin) <- UCI protocol paper ad= ds azithro
- if allergic, levofloaxcin (no need azithro then)
= - outpt Tx: amoxicillin 1g TID + azithromycin. If 65+, then augmenti= n BID + azithro

- if severe CAP and history of pseudomonas and penic= illin allergy, then levofloxacin and aztreonam.

- can do doxy= (also risk of tendon rupture) if azithromycin contraindicated for long QT<= br>
- HAP (cover pseudomonas and MRSA)
- Tx: zosyn 4.5g IV q6h= or cefepime 2g q8h, or cipro 400mg IV q8h, or imipenem 500mg q6h IV / mero= 1g IV q8h

- VAP (>48 hours after trach; cover S aures, pse= udomonas; cover MRSA if high risk)
- Zosyn 4.5g IV q6h or = cefepime 2g q8h + vancomycin 15mg/kg q8h
- if high r= isk factors (prior IV antibiotics, spetic shock, ARDS, hospitalized 5 or mo= re days before VAP, or dialysis), need 2 antipseudomonas from different cla= sses (cipro + cefepime + vanc)
- Tx duration:
- CAP: 5 d= ays; atypical: 10 days; legionella: 14 days; HAP/VAP: 7-8 days; p= seudomonas/acinobacter: 14 days; MSSA/MRSA: 14 days

- labs= : RPP, Procal, AFB sputum smear, Bcxz, sputum panel, fungal culture, CMB, h= isto, PJP, respiratory panel, Beta-D glucan, fungal Ab panel, BAL results, = aspergillus,
- even if legionella urine antigen negative, can stil= l be legionella (only tests for L. pneumophila serogroup 1)

aspirati= on pneumonia:
- outpt Tx: augmentin BID
- inpt Tx: Unasyn 3g q6h (bet= ter than cephalosporin due to anaerobic coverage); azithromycin + ceftriaxo= ne; only if empyema or lung abscess, then add on anaerobe

(start= doxy/azithro + ceftriaxone for all CAP)

HIV/AIDS
- legionell= a antigen, histoplasma galactomannan EIA, urine, strepcoccus pneumoniae ant= igen, PJP PCR BAL, respiratory viral panel, cryptococcal antigen and antibo= dy, LDH, coccicdiodes antigen, IgG/IgM, aspergillus galactomannan Ag, = ABG, Beta-d-Glucan (Fungitell)

Fungitell does not test for blasto c= rypto mucor

severe pneumonia
check CRP >2.4 has , start steroi= ds or not- CXR
- = consider procal
- consider ABG
- consider PFTs
- ceftriaone (and a= zithro)
- duoneb PRN

#pneumonia: {PNEUMONIA DX LIST:13= 0582} Overall assessment of severity: {SEVERITY:67} Meets diagnostic = criteria given new CXR consolidation AND fever/cough/leukocytosis/purulent = sputum/hypoxemia. Will treat for presumed bacterial pneumonia, but will eva= luate for viral causes as well given lobar consolidation. COVID negative. C= URB65 =3D ***. Port/PSI score =3D ***

- Sputum culture and = gram stain

- Blood cultures

- Procalcitonin=

- MRSA nares

- S. Pneumo urine antigen

- Legionella urine antigen

- Given inpatient status will treat w= ith CTX and azithromycin {consider Vancomycin as well}

- Gi= ven concern for aspiration pneumonia -- Zosyn vs unasyn (no pseudomonas). C= an consider deescalation of augmentin for outpatient treatment (7 d duratio= n)

- Flu PCR/ COVID PCR / Adenovirus/ Mycoplasma/ Parainfluenza/D= FA

- Lactate

- VBG

- = if pleural effusion, consider lasix

Likely HAP giv= en development of symptoms >48 hours after admission. IV antibiotics in = the last 90 days is the most important risk factor.

- Vanc = + Cefepime for anti-MRSA and anti-pseudomonal agent

POISONING

Ethylene glycol poisoning (CMP, lactic, B-OH, = etOH level)
- Tx: dialysis and fomepizole

methanol (CMP, lactic, = B-OH, etOH level)
- Sx: central blurry vision
Tx: fomepizole

l= ead poisoning
- Sx: abdominal pain, anemia, constipation, glove neuropat= hy
- dotted "stippling" RBCs
- level <45 =3D mild =3D monitor and = repeat lab in 1 month, >45 =3D moderate =3D oral succimer, >70 =3D se= vere =3D IV EDTA

cyanide poisoning
- nitroprusside becomes nitric= oxide and cyanide. In CKD pt, can build up
- Sx: confused ,seizur= e, vomiting
- labs: will have lactic acidosis
- Tx: 100% O2, IV fluid= s, hydroxcobalamin +/- sodium thiosulfate

carbon monoxide
- Sx: h= eadache, confusion, seizure
- labs: CK will also increase. get ABG= for carboxyhemoglbin level, EKG, trop
- Tx: high flow O2, hyperbaric O2=

iron toxicity
- Sx: GI bleed, coffee ground emesis
- Tx: defe= roxamine

aspirin
- Sx: tinnitus

tylenol
- Sx: nausea/vo= miting, but no kidney issue. AST/ALT in X000s; CMP, lactic, PTT/PT/INR
-= Tx: n-acetylcysteine

arsenic poisoning
- cause: pesticides, well water, pressure-treated wood
- S&S: garlic breath, vomit, diarrhea= , long QT, skin hypo/hyper-pigmented, glove -neuropathy
- Tx: dimercaprol

Beta blocker
- Sx: hypoglycemia (blocks liver from cr= eating glucose; but in normal use also decreases insulin sensitivity), unco= nscious, AV block, seizures
- Tx: fluid + atropine. IV glucagon (m= ore cAMP in cells) if refractory

Ca channel
- Sx: same as beta bl= ocker, but non-unconsciousness and hyperglycemic

antidepressant
-= Sx: dilated pupil, prolonged QRS, dry mouth, dilated pupils (anti-Ach)
= - Tx: physostigmine (inhibits AchE)

benzo
- Sx: drowsy, slurred s= peech, wobbly gait (breathing and vitals normal)

organophosphate (AC= hE inhibitor =3D too much Ach)
- Sx: miosis, diarrhea, drool, muscle wea= k
Tx: atropine, then pralidoxime

tylenol
- Tx: n-acetylcystein= e

pol= yarteritis nodosa
- medium-vessel vasculitis: S&S =3D nodular skin l= esions =3D medium vessel vasculitis.
- S&S: abdominal pain, 1-2 extr= emity MSK/neuro issue. (mononeuritis multiplex)
- guy will get aneurysms= and stenosis in big arteries, occlusive lesions in small ones.

vs.&= nbsp;

small vessel =3D ANCA
- S&S: airway, kidneys, eyes, ear= s, skin (palpable purpura)polymyalgia rheumatica
- Sx: 50+ yr old, pain at shoulders
-= Tx: steroid, which is for pain reliefpopliteal cyst
- if ruptured, goes to medial ankle= "crescent sign" ecchymosisPortal hypertension
- without documented varices, don't start = beta blocker (may change in future)
- if documented, start

portal= vein thrombosis#portal vein thrombosis: Fever of ***. WBC *** on admission. Leukopenia wi= th absolute lymph of ***. Unclear etiology for trigger, but acute por= tal vein thrombosis can be due to tumor invasion. Will cover for common eti= ologies of septic PVT -- Bacteroides fragilis or Escherichia coli.

#transaminitis: alk phos of ***, ALT ***, AST ***, dbili of *** -- = though R factor of *** consistent with a cholestatic picture, PVT is also c= ommonly found in cirrhosis, will evaluate for possible hepatitis or viral e= tiologies.

- AFP

- Viral hepatitis&n= bsp;

- CMV, EBV, HSV, HIV

- Liver MRI with contrast&nbs= p;

- Heparin per pharmacy (will need anticoagulation for six mont= hs provided there is no indication for long-term anticoagulation, such as a= permanent thrombotic risk factor that cannot be corrected or a thrombus th= at extends into the mesenteric veins)

- Utox

- Pa= renteral therapy with Ceftriaxone (2g daily) and flagyl (500 mg q8 hours) (= 05/03/20 - 5/17/2020) with deescalation to oral flagyl and a fluoroquinolon= e to complete a total duration of 4-6 weeks (05/03/20- 6/7/20)

- = Blood cultures

post-GI recommendations

- CLD x 3 days, then F= LD x 4 days, then soft diet x3 weeks (patient

already received th= ese instructions beforehand)

- Oral liquid Augmentin x 5 days, if= PCN allergy give cipro/flagyl

- PO pantoprazole or omeprazole BI= D x4 wks

- PRN Zofran tablets and limited prescription for liquid= Hycet

(hydrocodone-APAP)

POTS
- orthostatic intoleran= ce with a heart rate increase of 30/min or greater, often with a standing h= eart rate greater than 120/min within 10 minutes of standing or head-up til= t and in the absence of orthostatic hypotension
- Tx: adequate hydration= , wearing compression garments, instituting a graded exercise program, and = sleeping with the head of the bed raised= PPI
- aspiration ppx when undergoing anesthesia<= br>- NSAID ulcer
- critically ill patients
- upper GI bleed

PPI prophylaxis
- patients intubated > 48 hrs
- plt < 50, INR= > 1.5, or PTT 2x baseline
- GI bleed or ulcer in past year
- majo= r trauma with injury severity score 16+
- burn >=3D35%
- head inju= ry GCS <=3D10 and inability to follow simple commands
- spinal cord i= njury
- partial hepatectomy
- solid organ transplant periop in ICU- 2 antiplts (placix, aspirin, ticagerlo, cilostazol, dipyridamole
- 2 = of sepsis, ICU stay > 7 days, occult bleeding more than 6 days, or (high= steroid >250mg hydrocotrisone, 50mg methylpred, 60mg prednisone, 10mg d= examethasone), enteral feeding
hlh

pregnant outpt
- TDAP 27-36 weeks each = pregnancy
- 24-28 weeks: 2hr glucose challenge

pregnant:
- no = atenololpregnant=
- no ACE/ARB (toxic to baby kidney)
- no spirinolactone (male baby f= eminize)
= preop= optimization
- score: D= ASI calculates METS
- MELD > 15 no elective surgery
- correct c= oagulopathy
- referral for variceal screening
- diurese= , tap ascites; refractory ascites =3D high risk for HRS
- optimiz= e nutrition
- minimize opioids
- referral for liver tra= nsplant if MELD > 15, child-pugh C
- no alcohol for 3 months

- stop ACEI night before surgery to decrease risk of hypotension.= For HF patients, continue
- continue beta blocker, clonidine, ca = channel blocker.
- hold diuretic morning of surgery
- continue statin=

- when NPO, decrease lantus by 25%

if CV risk < 1%, p= roceed to surgeyr
if CV risk >%, METS

- screen for OSA with ST= OPBANG.
- incentive spiroemter

- stop warfarin 5 days before surg= ery
- stop DOAC 1-2 days before surgery; stop earlier if GFR < 50
= - stop heparin 4-6 hours before surgery
stop lovenox 12 hours before sur= gery
- restart heparin 1 day after surgery
- restart warfarin 12-24 h= ours after surgery
- restart DOAC 1 day after surgery
- for Afib with= mechcal valve, Afib with CHADSVasc 7+, mod or severe mitral stenosis, rece= nt TIA/CVA, aortic mechanical valve - bridge heparin.
- plavix 5 days- aspirin normally (5-14 days off)

preop

RCRI
- 1) MI/CAD, CHF , DM on insulin , CVA, Cr = > 2.0, high risk

Pulmonary:
age, COPD, smoking, OSA,= albumi, pulm HTN, albumin
- gastric empty before
- BIPAP/CPAP<= br>- incentive spirometer

if only 1 home med ACEI, continue it, = else hold on day of surgery

Pre-operative pulmonary ri= sk stratification:

- ARISCAT score: 50 points, for an operation w= ith a Intrathoracic surgical incision, which lasts 3+ hours.

- Perioperative risk category: High.

- This correlates with a 4= 2.1% risk of in-hospital post-op pulmonary complications (composite i= ncluding respiratory failure, respiratory infection, pleural effusion, atel= ectasis, pneumothorax, bronchospasm, aspiration pneumonitis)

- Ne= ither ARISCAT nor AROZULLAH respiratory failure index take OSA, obesity, pr= esence of ILD or heart failure or pulmonary hypertension into consideration= in regard to perioperative pulmonary complication risk stratification.

The patient does not have a dx of COPD.

A= rozullah Respiratory Failure Index: 35 points (10.1% risk of respiratory fa= ilure during postoperative period of noncardiac surgery

Gupta Pos= toperative Respiratory Failure Risk: 1.2% risk of mechanical ventilation fo= r >48 hrs after surgery, or unplanned intubation =E2=89=A430 days of sur= gery

Gupta Postoperative Pneumonia Risk: 1.5% risk of postoperati= ve pneumonia

In general, to decre= ase the risk for perioperative pulmonary complications, please consider:

1) Minimizing general anesthesia time

2) Avoiding general= anesthesia when possible

3) Peri-operative use of bronchodilator= s

4) Extubation to non-invasive positive pressure ventilation (Bi= PAP)

5) Aggressive post-op incentive spirometry

6) Aggr= essive post-op pulmonary toilet

7) Early mobilization post-op

- Pulmonary hygiene, incentive spirometry, PT/OT, OOB as tolerated

preventative care
- 50+ =3D shingles and pneumovax
- 65+ =3D = prevnarPRN pain = meds
- mild: tylenol 650 q6h or ibuprofen 600 PO q8h
- mod: nap= roxen 250 q8h, ketoralac (Toradol) 10mg PO q6h or 15mg IV for 5 days max (m= ax dose 40mg/day), tramadol 50mg PO q4h, tylenol-codeine 300-30 q4h PRN
=
antidote: naloxone 0.4mg IM/IV q2-3m PRN

anxiety:
- ativan 0= .5 PO q6h PRN for anxiety, or 0.5mg IV q4h
- xanax (alprazolam) 0.= 25mg q6h
- zolpidem (Ambien) 5mg qhs for insomnia

diarrhea<= br>- peptobismol, imodium

vomiting
- zofran 8mg q8h PO or 4mg IV = q8h
- promethazine (Phenergan)
- prochlorperazine (Compazine)
- me= toclopramide (Reglan)

(if caused by opioid, chemo, toxin, or drugs, = - target GI tract or chemoreceptor trigger zone =3D antidopamine good =3D c= ompazine, phenergan, haldol, metoclopramide, chlorpromazine, olanzapine -- = SE: sedation, hypotension, dystonia, pseudoparkinson)

cough
-= guafenesin 200 q4h
- tessalon 200mg TID
- dextromethorphan-gua= fenesim (mucinex DM) 1-2 tabs 12h (max 4 day)

itching
- benadryl = 25mg PO q6h or IV q6h

HTN
- hydralazine 10mg q4h
- labetalol 1= 0-20mg q15m

Breathing
- duoneb (albuterol-ipatropium) 3cc q4hProcedures
- par= acentesis: >8cm away from midline and >5cm above pubic symphysis = ; (4+cm pocket to tap)

- if air embolism when pulling central line o= ut, lie patient on left side so air bubble stairs on R side of heart. Give = high flow O2 (encourageds bubble absorption)

- weighted tip-tube: mu= st be post pyloric
- non-weighted tip tube: can be in stomachprotein gap

#elevated protein gap / gamma g= ap: >3.5-4 is considered elevated. Low concern given low albumin // elev= ated concern given elevated total protein level.

- SPEP, UP= EP

- immunofixation

- Serum free light chain

= - If immunofixation shows elevated Ig levels -- would order immunoglobulin = levels

- Consider Heme/Onc consult for additional workup an= d biopsy

Proteinuria
>65 and proteinuria >= 3.5g, CT non-con for malignancy before kidney biopsy. Also test for = antiphosolipiase A1 receptor
ESRD with cysts, higher risk for RCC; annua= l ultrasound
myeloma castg nephropathy - start chemo

ANCA-associa= ted vasculitis typically presents as a rapidly progressive glomerulonephrit= is - erythrocytes and erythrocyte casts on urine microscopy.

pseudomonas risk factor= s
- prior pseudomonas, structural lung disease (bronchiectasis, CF), fre= quent COPD with steroid or Abx use, IV Abx in last 3 months, long term care= , AIDS, severely malnourished, recent hospitalization 3 months, chronic hem= odialysis, profound neutropenia

Tx:
- zosyn (piperacillin-tazoba= ctam)
- ceftazidine (3rd gen)
- cefepime (4th gen)
- meropenem and= imipenem (NOT ertapenem)
- aztreonam
- ciprofloxacin & levofloxa= cin
- gentamicin (aminoglycoside)

if need pseudomonas and anarobe= s, then zosyn, aztreonam+flagyl if allergic to zosynpsych hold
- 5150: <=3D72 hours if= patient unwilling to accept voluntary treatment AND is DTS, DTO (danger to= others), or GD (gravely disabled: cannot care for self)
- 5585: <=3D= 72 hours for minors same as above
- 5250: <=3D 14 days for DTS/DTO/G= D
- 5260: <=3D 14 day extension of 5250 for DTS only
- 5270: <= =3D 30 day hold for GD only
- 5300: <=3D180 hold for DTO
- 5350: 3= 65 day conservatorship for GD
- 5352: temp conservatorship prior to cour= t ruling

= ptsd
- do not prescribe benzo

OCD
- CBD + SSRIpulmonary hypertension
resting= pulmonary aterial pressure > 20mmHg (vs. 25?) and PCWP <15mmHg and P= VR (resistance) < 3
- group 1 =3D PAH
group 2-5 =3D left sided hea= rt disease, COPD/ILD/sleep, DVTs

- Tx for PAH: tadalafil and ambrise= ntan; calcium challne blocker
- O2 therapy if O2 sat < 90%

Work up:

-continue with diureses with at least net goal of -1-2L/d= ay

-when euvolemic please order repeat TTE with bubble study = ;

-please order PH work up

&= nbsp; -Images: RUQ US with doppler (check for portal htn)

&= nbsp; -labs: hepatitis panel, hiv, tsh/t4, urine drug = screen, ana,

dsdna, rnp, rna po= lymerase III antibody, scl-70, anti-centromere

= ; B antibody

-please or= der V/Q scan and PFTS (with dlco, plethysmography, and post

bronchodialator response) for outpatient when = discharged

pulmonary nodule
- 6-8 need chest CT in 6-12 months, if s= ame size, then 2 year intervals for 5 years
- 8mm+: 3-month CTfollow-up,= work-up with combined PET/CT, or tissue sampling PVCs / Vtach (VT)
- suppression w= ith verapamil or B blocker (does not work if has structural issue)
- if = non-sustained VT, should have exercise treadmill testing to provoke arrhyth= mia, echo (for any structure heart issues)

nonsustained VT
- <= 30 s (Any wide QRS Should be considered VT unless proven)

- if hemod= ynamic stable, can trial IV procainamide, amiodarone, lidocaine, sotalol fo= r sustained VT
- if not stable, CV.

sotalol need 5 doses = monitoring for steady stateradiology

SBO: dilated small bowel >3cm and little gas= in colon (causes, adhesion, malignancy, hernia, gallstone ileus, IBD) - sm= all bowel has segment lines fully across
LBO: colon dilated then no gas = after, no air in rectum (causes: tumor volvulus, hernia, diverticulitis) - = large bowel haustra, no line fully across
localized ileus: 1-2 dilated l= oops (causes: chole, pancreatitis, diverticulitis, appendicitis); can also = see transverse colon being dilated ("sentinel loop" =3D early sign of pancr= eatitis)

good resource: https://www.radiologymasterclass.co.uk/= raynaud
- Tx:= nifedipine/amlodipine (dihydropyridine type)reactions

- vancomycin "red man syndro= me" =3D mast cell activation.
- Tx: benadryl
- vancomycin can also ca= use anaphlyaxis =3D epireactive arthritis
- Reactive arthritis is a rare cause of in= flammatory arthritis that can occur following specific genitourinary and ga= strointestinal infections, including Chlamydia trachomatis and Ureaplasma u= realyticum in the urethra and Campylobacter, Escherichia coli, Salmonella, = Shigella, and Yersinia in the intestine
- Sx: 2-3 weeks after infectio, = asymmetric and can be 1 or multiple joints. Can also get k= eratoderma blennorrhagicum(psoriasiform rash on palms, toes, and soles of t= he feet), conjunctivitis (more common than anterior uveitis) and circinate = balanitis (psoriasiform rash on penis)restless leg syndrome
- check iron. give iron if f= erritin < 75
- Tx: pramipexole, ropinirole, gabapentinReversals:
- warfarin: KCentr= a (PCC) (UCI does FFP + vitamin K)
- heparin: protamine
- DOAC: andex= anet alfarhabdo<= br>- CK> 5000, bolus 1L NS, then LR 3cc/kg/hr, urine output goal 200cc/h= r (3cc/kg/hr). If more, decrease IVF 1cc/kg/hr (min 2cc/kg/hr), if le= ss, if hypovolemic, increase 1cc/kg/hr (max 5cc/kg/hr); if overloaded, diur= ese.
- CK q8h, if <5000 x2, then can stop treatmentrheumatoid arthritis
- test: RF,= anti CCP; XR of joint; if destruction of MCP/PIP and lab negative, still a= diagnosis of RA
- Tx: NSAID for flare, then methotrexate and folate
= - need hepatitis and TB labs= rheum

Puffy fingers (sclerodactyly), dysphagia/esopha= geal dysmotility, raynaud=3D sclerodema. If affect internal organs to= o, then "systemic sclerosis". Can be CREST (calcinosis fingers, rayna= ud, esophageal, and telangictasia, or diffuse systemic =3D lung, kidney, GI= tract too.
systemic sclerosis
- test: anti-Scl-70 (anti-topoisomeras= e), anticentromere

sclerodema acute renal crisis, then ACEI Captopri= l (because short onset). If malignant HTN, then give nitroprusside.
rotem/teg 3D""

RRT - altered mental status
- consid= er: baseline, recent intervent, meds
- Cause:
- metaboli= c: hepatic encephalopathy, acidosis, electroytes (Na, Ca, Mg, Phos)
&nbs= p; - O2: hypoxia, hypercarbia, anemia, decreased cerebral flow (occlusion, = decrease cardiac output from cardiogenic shock), sepsis
- vascula= r: hemorrhage, stroke, vasculitis
- endocrine: glucose, thyroid, = cortisol
- seizure: post-ictal vs status, hydrocephalus
= - tumor, trauma
- uremia
- psychiatric/deliriu
&nbs= p; - infection/ingestion
- drugs: intox, withdrawal, pca
ain m= eds, benzo, antiAch
- manage:
1) can protect airway? -&g= t; intubate
2) reversible cause: meds, recent procedures (anesthe= sia/pre-medications)
3) if concern stroke, call code stroke and N= IHSS
4) escalate if airway, need frequent neurochecks, increasing= nursing needs for patient safety

#Altered mental status: Ddx includes metabolic, infectiou= s, drugs vs medications, primary CNS, delirium.

<= div>Patient's acute AMS concerning for trauma vs vascular vs increased ICP,= meds/toxins, metabolic.

- EKG to evaluate for arrhythmia&n= bsp;

- UTox for possible substance abuse

- AM cor= tisol, TSH

- Bladder scan for urine retention

- Seizure, stroke, syncope

- CBC, BMP, LF= T, lactate, NH3, B12, TSH, VBG, UA, CXR, bladder scan

- ESR= , CRP, CK, B12, B12

- TTP consideration (low platelets, anemia, r= enal failure, fever, neuro changes) -- LDH, stat smear

- El= evated T,HR,BP,RR concerning for serotin syndrome >> neuroleptic mali= gnant syndrome

- Consider EEG

- Co= nsider MRI w/ gad for possible stroke vs malignnancy

- Cons= ider LP

- HIV, RPR, HSV, VZV,

- Deliriu mpr= ecautions

- In setting of immunsuppression, = f/u on

- Blood cultures (fungal as well)

- Sputum cultures

- 1,3 BD glucan

- Galactomannan

- Histo urine / = serum antigen

<= span style=3D"white-space:pre"> - Crypto antigen

<= div>

- Concern for seizure

- Continuous EEG

- Start renal dose Keppra 500 mg BID with additional 500 mg given = back after each HS session and continue indefinitely

- for recurr= ent electrographic or clinical seizure give weight based Ativan IV (1mg/kg = up to 4 mg per dose, up to 2 doses)

- consider escalating abx reg= imen to meningitic dosing and adding empiric amp and acyclovir; pt may not = be able to undergo LP given thrombocytopenia

RRT - hypotension
-= consider: recent interventions, accurate BP reading?, baseline
- Assess= : WARM OR COLD (hypoperfusion, lactate would be high too)
- Cause: =
- hypovolemic: dehydration, hemorrhage
- cardiogenic: = HF, tachy, MI, tamponade
- distributive: sepsis, anaphylaxis, aci= dosis
- obstructive: PE, pneumothorax, aortic dissection, neuroge= nic
- other - medications, acidosis, BP monitor, cortisol, hypoth= yroid
- Manage:
1) volume status - diurese vs fluid
= 2) symptomatic - fluid, antibiotics, steroid, pressors
3) reversi= ble cause: recent meds, fluid shift
4) beside echo for tamponade,= cardiac function R heart size, IVC, pneumothorax
5) escalate if:= pressors, lack of response to above

- if steroid use, possible adre= nal insufficiency
- labs: morning cortisol, cosyntropin stim test
- midodrine TID (20 TID max in ICU; outside seems 10 TID); cannot give if = HFrEF- CBC, CMP, Lac= tate, TSH/FreeT4, UA, BCx, Trop
- CXR, EKGRRT - SOB
- consider: b= aseline, recent intervention, accurate pulse ox
- cause:
= - pulmonary: pneumonia, pneumothorax, PE, pleural effusion, hemothroax, as= piration, bronchospasm, upper aiway obstruction, TRALI
- cardiac:= MI/ischemia, CHF/volume, arryth, tamponade, valvuopathy
- metabo= lic: acidosis, hypoPhos
- hem: anemia, anaphylaxis
- ps= ych: anxiety, withdrawal
- meds: aspirin, carbon monoxide, benzo = intoxication
- obesity, ascites
- management:
= 1) stablize airway? (bag? intubate?)
1) elevate head of bed
&n= bsp; 2) supplemental O2 (NC, non-rebreather, high flow, BIPAP)
3)= continuous pulse ox
4) med intervention: duoneb, diuretic, ABx, = steroid, narcan
5) escalate: unstable airway, impending compromis= e, lack of response to above

- Narcan 0.4-2mg IV q2m if caused by op= ioid
- if high suspicion for PE, start empiric AC
- BIPAP for COPD; C= PAP for CHF if accessory muscle, pH<7.35, breathing fast and still PaCO2= >45
- epi 1:1000 0.3cc (i.e 0.3mg) IM q5 m PRN, diphenhydramine 25-50= mg IV, neb albuterol, methylpred 1-2mg/kg IV

NC: every L increases 3= FiO2 (6L NC =3D 40 FiO2)
simple face mask needs 5-10 L, if <5L, will= rebreath CO2
Non-rebreather (consider 1st if acute hypoxemic): i= f tachypneic, FiO2 0.6 better due to entrapment of room air, else can give = FiO2 90

PaO2<60 =3D hypoxemic
A-a gradient (normal =3D Age/4 += 4). if elevated, bad; A-a gradient > 20 =3D abnormal gas exchange =3D gl= obal hypoventilation
PAO2 alveolar =3D FiO2in decimal x 713 - PaCO2= /0.8
PaO2 arterial =3D by blood gas
- give high PEEP if can't breath<= br>If A-a elevated and PaO2 corrects with oxygen, then VQ mismatch, e= lse shunt (alveolar collapse or diffuse alvolar disease) or impaired diffus= ion (decrease DLCO).
If not, then hypovenitlation or decreased FiO2 (hig= h altitude)

respiratory acidosis (pCO2 high);
compensation:
&= nbsp; if acute, HCO3 increase by 1 every pCO2 up by 10
if chronic= , HCO3 increase by 4
respiratory alkalosis (pCO2 low)
if acute= : HCO3 decrease by 2 every pCO2 down by 10
if chronic: HCO3 decre= ase by 5

respiratory acidosis
- expected pH =3D 7.4-(differen= t of pCO2-40 x0.08)-= CBC, CMP, ABG, CXR, EKG
- continuous pulse ox
- trop, BNP, lactate,&= nbsp;
- TTE for RV strain, head CT if suspect stroke, CT PE if PE

A-a gradient =3D PAO2 - PaO2 =3D (FiO2*(Patm - H2O pressu= re) - (PaCO2/0.8) - PaO2. H2O pressure=3D47

Normal A-a gradient = =3D (age/4) + 4

Differential for increased A-a gradient (>10) = includes V/Q mismatch (obstructive lung disease, PE (CTPA negative 5/23), p= ulmonary edema, PNA, ILD (no evidence of this), atelecatsis), shunt (either= anatomical or physiologic related to PNA/ARDS/atelectasis), and diffusion = limitation (fibrosis, edema).

RTA 1 - cannot excrete= H+, urine pH >6
type 2 RTA - cannot get back Bicarb =3D urine pH <= ; 5.5
RTA 4 - high K (aldosterone deficiency or resistance)sacroiliac joint dysfunction<= br>- Sx: FABER test positive (flexion, abduction, external rotation) poster= ior hip pain

hip osteroarthritis
=3D old person with posterior hi= p pain, groin pain and FADIR test (flexion, adduction, internal rotation)
acetabular labrum tear
- young athlete jumping or sprinting, anter= ior hip pain
- FADIR test positivesarcoidosis
- common in african american young adult=
- non-caseating granuloma biopsy
- test: CXR bilateral hilar lymphad= enopathy, ACE level very high
- Sx: large liver, one side face droop, uv= eitis, erythema nodosum, dilated/restrictive cardiomyopathy,

-= if sarcoidosis causing arrythymia, immunotherapy actually improves the arr= ythmia (instead of beta blockers)SBO=

#Small bowel obstruction: likely secondary from adhesions from previou= s abdominal surgeries/hernia/cancer with intussusception / volvulus / forei= gn bodies / stricture. Patient's hypokalemia and hypochloremic metabolic al= kalosis likely form repeated emesis. Ischemia from strangulation likely cau= sing lactate / leukocytosis. Imaging shows air-fluid levels and dilated bow= el proximal to and decompressed bowel distal ot obstruciton.

- NPO

- Large bore NGT 18 F to continuous low wall suctio= n, goal <200 cc output

- Surgical onsult to consider surgical = options given strangulation / bowel ischemia if no improvement in 72 hours&= nbsp;

- Menthol drops for throat pain 1st line

- = Lidocaine viscous solution for throat pain 2nd line

- Mucos= itis mixture for throat pain 3rd line

SBP
-= If has peritoneal dialysis: need 2 or 3 criteria of >100 pmn, culture f= rom effluent, symptoms (nausea vomiting). Use indwelling antibiotics (vanc,= ceftazadine), and nystarin swish and swallow
- else pmn> 250

=
- Tx: prophylaxis on SBP - daily bactrim or cipro

#SBP:

Patient with = PMN of *** on diagnostic paracentesis (9/30). Fluid cultures of abdomen wit= h ***.

2014 study in Gastroenterology showed that among pat= ients with SBP, NSBBs reduced transplant-free survival (hazard ratio =3D 1.= 58; 95% confidence interval: 1.098=E2=80=932.274; P =3D .014) and increased= days of nonelective hospitalization (29.6 days/person-year in patients on = NSBBs vs 23.7 days/person-year in those not taking NSBBs). A higher proport= ion of patients on NSBBs had hepatorenal (24% vs 11% in those not taking NS= BBs; P =3D .027) and grade C AKI (20% vs 8% for those not taking NSBBs; P = =3D .021). Despite this though, this patient would likely benefit from nons= elective beta blockers given his high risk of esophageal rebleed. Would rec= ommend low dose beta blockers until esophageal varices have resolved, and o= nce they have, should have his nonselective beta blockers discontinued.&nbs= p;

#Cirrhosis, decompensated with variceal hemor= rhage and ascites.

MELD-Na score: ***

MELD score: ***

? Etiology: ***

?= Ascites - *** seen on Abd US.

? Hepatic encephalopathy - ***&= nbsp;

? Varices - ***

Recommendations:

? Will need CTX for SBP dosing (2g every 24 hours (10/1 - 10= /6)) with 25% albumin (1.5 g / kg on day 1, 1 g/kg on day 3, max of 100 g)&= nbsp;

? In= itiate propranolol at low dose, 10 mg BID for prophylaxis of esophageal ble= ed.

? Cont= inue octreotide gtt

<= span style=3D"white-space:pre"> ? <= /span>Continue Protonix IV 40 mg BID

? 2 g Na restriction

? Initiate secondary prophylaxis for SBP wi= th PO cipro 500 mg qd or PO Bactrim DS qd

? Would recommend therapeutic paracentesis = to decrease intraabdominal pressure to minimize risk of esophageal bleed.&n= bsp;

? CBC q 4h = in pediatric tubing to determine if and when endoscopy is appropriate =

? Transfuse goa= l Hgb >7, Platelets > 50k, INR <2.5

? Please order iron panel, ferritin, B12, fo= late, vitamin D, vitamin B12

? Once hemodynamically stable:

? Will benefit from diuretic treatment (likely= 100 mg/day spironolactone and 40 mg/day of furosemide and adjust to mainta= in normokalemia though should be managed through either liver consult or ou= tpatient follow up with liver clinic) with goal weight loss of 0.5 kg / day= to avoid AKI.

= ?= Social work for alcohol cessation resources -- will need 6 months s= obriety to be considered for liver transplant.

?= Will need follow up in with Santa A= na clinic to arrange for repeat EGD, after which beta blockers can be disco= ntinued if varices have resolved to prevent complications from SBP and beta= blocker therapy.

SBP
- prevent wi= th cipro or bactrim
- inpt: cefotaxime/CTX

- for hepatorenal = syndrome, trial albumin. (Stop diuretics!)

SBT
- riskby score <105 (machine sho= ws F/T on top right) means successful likely. Higher doesn't mean will fail= though.
- need strong cough (trial it)
- SBT is switch to pressure s= upport
Racemic epi or solumedrol after extubate to decrease secretions i= f a lot
- possible get ABG after SBT and concerned won't succeed
- pl= an for what if happens fail (trach?)

(pressors decreasing, test = can lift arm/neck, FiO2 <50%, pressure support 5/5, or 8/5, hear cuff le= ak only if suspecting edema; NIF -20)- A-line, central-line
- MAP > 65schizopre= nia
- if males, manifests 15-25s. If old man, visual hallucination= s/delusions (psychotic) cannot be due to psychiatry.
- if female 2= 0-30s or perimenopausal time
Charles Bonnet Syndrome =3D cataract = causing visual hallucinations for older people
- Tx: 2nd gen antipyschot= ic (olanzapine, respiridone, quetiapine, aripiprazole) and refer to psych
sciatica- Sx: pain, tingling, numbness to leg

round ligament pain
- shar= p pain in abdomen, hip, groin, worse with fast movement and change; pain do= es not radiate; negative straight leg

sacroilitis:
- Sx: pain wit= h palpation of sacroiliac joint, straight leg negative
- positive FABER<= br>
greater trochanteric pain syndrome
- pain at lateral hip, wose wh= en sleeping on side
- cause: friction between greater trochanter and IT = band causing trauma to gluteal tendon
- positive FABER and pain on palpa= tion
- Tx: PT, NSAID, weight lossscreening
- colorectal: 45+ until 75 (life expectanc= y is >10 years or if living long time)
- pap smear: 21-29 pap every 3= , reflex HPV. 30-65 q5 years
- mammogram: 40 (https://www.mdcalc.c= om/calc/3647/gail-model-breast-cancer-risk. if > 20%, start at 30 years,= then MRI and mammogram due to high risk); initially every year until 50, t= hen every other year (at age 40+, 10% false positive for screening) until 7= 5.
- lung cancer: 55-80 who quit within 15 years and smoked 20 pack-year=

serotonin= syndrome
- Sx: diarrhea, tachy, sweating, hyperreflex, tremor, d= ilated pupils, anxious
- Tx: supporticve + benzo. If doesn't= work, the cyproheptadine- doppler
- aspirin 81mg (+rivaroxavan 2.5mg BID shown to be better= than aspirin alone) if symptomatic (pain on exertion relieved by rest)
= - ABI
- atorvastatin 40mg, smoking cessationsevere AS
- if hypote= nsive shock requiring pressor, 1st pressor is phenylephrine (increase after= load to push blood back to coronaries)shingles
- 7 days oral valacyclovir.&nbs= p; Cover it to not spread to others until fully crusted. IF dissemina= ted (Goes other place than first site, then must have contact and airborne = precautions and admit to hospital for IV valacyclovir).
- If pain still = from shingles after 4 months, gabapentin. Before that, NSAIDS
shocks
- cardiog= enic - high PCWP
- hypovolemic - low PCWP
- obstructive - tamponade, = PE, tension pneumo
- anaphylatic - high cardiac output and low systemic = resistance
- septic shock - high cardiact output and low systemic resist= ance 3D""

shoulder joint

lab= ral tear
superior labrum anterior and posterior lesions (SLAP)
- repe= titive overhead stress / weightlifting or throwing
- Sx: pain with abduc= tion and external rotation, catching of joint, joint instability, creptius<= br>
AC joint degeneration =3D poorly localized pain, strength and ROM no= rmal
- test: pain with adduction of arm across body (Cross-arm) and shou= lder abduction >120degrees

bicep tendinopathy
- repetitive lif= ting and carrying
- Sx: pain at anterior shoulder, radiate to deltoid, w= rose with overhead
- test: pain by palpating long head of biceps t= endon, pain with arm at side while flexing elbow and supinate against resis= tance

rotator cuff tendinopathy
- Sx: pain worse at night, lying = on affected side, with overhead activity; pain to upper arm near deltoid.- test: pain at 60-120 degrees of passive abduction (=3D positive painful= arc test), empty can test
- Tx: rest, tylenol, PTshoulder pain
- rotator cuff tear = =3D pain with weakness
- tendinitis =3D no weakness
- impingement syn= drome =3D pain with reaching
- adhesive capsulitis =3D stiffness =3D no = active/passitve abduction/external rotation
- MRI ideally for tear, but = U/S cheaper
- Tx: NSAID and exercise (do NOT sling). If full tear,= then surgerySick= le cell

#Sickle = cell disease:

Major acute complications include infection, = severe anemia (splenic sequestration, aplastic crisis, or hyperhemolysis), = vasoocclusive phenomena (acute vasoocclusive pain, stroke, acute chest synd= rome, renal infarction, dactylitis, myocardial infarction, pregnancy compli= cations, priapism, VTE). Chronic complications include chronic pain, anemia= , neuro deficits, seizures, pulmonary conditions, renal impairment, osteopo= rosis, cardiomyopathy with diastolic dysfunction, hepatotoxicity due to tra= nsfusions and medications, reduced growth, chronic leg ulcers, proliferativ= e retinopathy.

However, patients with chronic hemolysis (such as sickle cell anemia) who = depend on increased erythrocyte production can have significant anemia with= a decreased reticulocyte count.

- Heme/onc consul= t to discuss allogenic BMT given curative potential.

- Disc= uss hydroxyurea given ability to prolong life expectancy (increase fetal he= moglobin levels and generate nitric oxide) -- would be appropriate given **= * frequent pain crises, severe symptomatic anemia, or previous acute chest = syndrome or stroke

#vaso-occlusive events

Opiates are the preferred analgesic, with the exception of meperidine, wh= ich can cause seizures.

Chronic pain is exac= erbated by emotional stress, anxiety, insomnia, and depression and is perha= ps best treated with a holistic approach emphasizing nonopioid options such= as NSAIDs, relaxation techniques, massage, and biofeedback.

- Alternative medicine Integrative health

- Two new treatments -- oral L-glutamine (precursor to NAD) = and P-selectin inhibitor (crizanlizumab)

#ac= ut chest syndrome: clinical diagnosis based on the constellation of fever (= >38.6 =C2=B0C [101.5 =C2=B0F]), tachypnea, hypoxia, cough, shortness of = breath, and a new pulmonary infiltrate.

O2 to treat hypoxia= and the use of empiric antibiotics to treat infection

pulmonary hypertension is a recognized complication of SCD found in up= to 30% of patients, typically presenting as worsening right heart failure.=

#stroke:

Monthly transfusion begu= n after a stroke can reduce the incidence of subsequent stroke by 50% but c= arries the risk of iron overload necessitating iron chelation. Hydroxyurea = may also help in stroke prevention.

Rapid initiation of opioids for vaso-occlusive crisis=

Use of incentive spirometry in hospitalized patients

U= se of analgesics and physical therapy for treatment of avascular necrosis

Use of ACE inhibitors in patients with microalbuminuria

= Regular ophthalmologic examinations and referral for laser photocoagulation= for retinopathy

Use of echocardiography to evaluate signs of pul= monary hypertension

Hydroxyurea for patients with more than 3 vas= o-occlusive crises per year, for those with pain or chronic anemia interfer= ing with daily activities, or those with recurrent acute chest syndrome

Preoperative transfusion to serum hemoglobin level of 10 g/dL (100 g= /L) for surgeries requiring general anesthesia

Assess for iron ov= erload and begin oral iron chelation if necessary

Strong Recommendations from the National Institutes of Healt= h/U.S. Department of Health and Human Services Guidelines for the Managemen= t of Sickle Cell Disease

. Patients= undergoing surgical procedures requiring general anesthesia should receive= PRBC transfusion for a target hemoglobin level of 10 g/dL (100 g/L) to avo= id surgical complications.

Monthly transfusi= ons (hypertransfusion) in patients with an initial stroke can reduce the in= cidence of subsequent stroke and reduce stroke occurrence in patients at ri= sk for stroke based on cranial Doppler arterial velocity.

<= br>

With any transfusion, care should be taken to keep hemoglobin= concentrations less than 10 g/dL (100 g/L) to avoid problems with blood hy= perviscosity.

sickle cell
- funtional asplenia f= rom repeat microinfarcts
- risk of salmonella (encapsulated bacteria).- for any injury that doesn't heal, give ceftriaxone + clindaymcin

#Sickle cell disea= se:

Major acute complications include infection, severe ane= mia (splenic sequestration, aplastic crisis, or hyperhemolysis), vasoocclus= ive phenomena (acute vasoocclusive pain, stroke, acute chest syndrome, rena= l infarction, dactylitis, myocardial infarction, pregnancy complications, p= riapism, VTE). Chronic complications include chronic pain, anemia, neuro de= ficits, seizures, pulmonary conditions, renal impairment, osteoporosis, car= diomyopathy with diastolic dysfunction, hepatotoxicity due to transfusions = and medications, reduced growth, chronic leg ulcers, proliferative retinopa= thy.

However, = patients with chronic hemolysis (such as sickle cell anemia) who depend on = increased erythrocyte production can have significant anemia with a decreas= ed reticulocyte count.

- Heme/onc consult to discu= ss allogenic BMT given curative potential.

- Discuss hydrox= yurea given ability to prolong life expectancy (increase fetal hemoglobin l= evels and generate nitric oxide) -- would be appropriate given *** frequent= pain crises, severe symptomatic anemia, or previous acute chest syndrome o= r stroke

#vaso-occlusive events

Opiates = are the preferred analgesic, with the exception of meperidine, which can ca= use seizures.

Chronic pain is exacerbated by= emotional stress, anxiety, insomnia, and depression and is perhaps best tr= eated with a holistic approach emphasizing nonopioid options such as NSAIDs= , relaxation techniques, massage, and biofeedback.

- Alternative medicine Integrative health

- D5 1/2NS= @ 120 cc/hr

- Two new treatments -- oral L-= glutamine (precursor to NAD) and P-selectin inhibitor (crizanlizumab)

- Heme/onc consult for oxybryta (voxelotor) -- there is a global thera= peutic's free supply program "GBT source" for uninsured patients for oxbryt= a while case management assisting patient obtain insurance.

<= /div>

#acut chest syndrome: clinical diagnosis based on the constellati= on of fever (>38.6 =C2=B0C [101.5 =C2=B0F]), tachypnea, hypoxia, cough, = shortness of breath, and a new pulmonary infiltrate.

O2 to = treat hypoxia and the use of empiric antibiotics to treat infection

pulmonary hypertension is a recognized complication of SC= D found in up to 30% of patients, typically presenting as worsening right h= eart failure.

#stroke:

Monthly tra= nsfusion begun after a stroke can reduce the incidence of subsequent stroke= by 50% but carries the risk of iron overload necessitating iron chelation.= Hydroxyurea may also help in stroke prevention.

Rapid initiation of opioids for vaso-occ= lusive crisis

Use of incentive spirometry in hospitalized patient= s

Use of analgesics and physical therapy for treatment of avascul= ar necrosis

Use of ACE inhibitors in patients with microalbuminur= ia

Regular ophthalmologic examinations and referral for laser pho= tocoagulation for retinopathy

Use of echocardiography to evaluate= signs of pulmonary hypertension

Hydroxyurea for patients with mo= re than 3 vaso-occlusive crises per year, for those with pain or chronic an= emia interfering with daily activities, or those with recurrent acute chest= syndrome

Preoperative transfusion to serum hemoglobin level of 1= 0 g/dL (100 g/L) for surgeries requiring general anesthesia

Asses= s for iron overload and begin oral iron chelation if necessary

. Patients undergoing surgical procedures requi= ring general anesthesia should receive PRBC transfusion for a target hemogl= obin level of 10 g/dL (100 g/L) to avoid surgical complications.

Monthly transfusions (hypertransfusion) in patients wi= th an initial stroke can reduce the incidence of subsequent stroke and redu= ce stroke occurrence in patients at risk for stroke based on cranial Dopple= r arterial velocity.

With any transfusion, c= are should be taken to keep hemoglobin concentrations less than 10 g/dL (10= 0 g/L) to avoid problems with blood hyperviscosity.

= smoking
- patch- 1.5x effective (caution in recent MI, arrythmia, or che= st pain but still okay) - -use combination of long atching patch and short = acting gum/spray/lozenges to be more effective
- bupropion - 2x - avoid = with seizure or eating or history of suicide ideation
- varnicline (Chan= tix) - 3.5x; use with patch for best effortspep, upep, immunofixation, serum light ch= ain, immunoglobulin for lymphoma/ waldernstrom/MGUS

UPEP, SPEP, serum immunofixation, urine immunofixation, copperspinal stenos= is
- worse with walking and extension; better with sitting and leaning f= orward
- S&S: romberg test positive (falls with eyes closed) and wid= e gaitspine
<= br>spinal stenosis
- Sx: pain better when leaning forward, worse with wa= lking up steps/extending back

diabetic amyotrophy
- asympatic wea= kness with atrophy and weight loss; acute, focal onset of pain, then weanes= s of proximal leg.splen vein thrombosis left side - do splenic embolization; right sid= e can also do to decrease splanchnicsplenic vein thrombosis
- complication of pancreatit= is

sinesto cirrhosis- if has SVT, spleen still needs to drain blood,= so goes through short gastric vein (will have splenic thrombosis)&nb= sp; !!! don't do biopsy of variaceal gastric/varices, else will bleed outSponsyloksing arthr= itis us actually more tendon inflammation not arthritis as symptom (enthesi= tis)
If xr negative, mri more specificSsti
Augmentin not as good due to poasible resi= stance. Use cephalosporin. Near 99% coverage
Also CAP. Unless outpt. If = healthy amoxicillin. With comorbidity, augmentin. All CAP with azithr= o.

Steroid contraindicated in fluSTDs
syphillis
- syphillis if caught ea= rly =3D 1 dose penicillin. If >12 months or unknown when, then onc= e a week for 3 week. If neurosyphillis, every 4 hours. After st= arting treatment will feel worse (Jarisch-Herxheimer reaction =3D lysis of = bacteria); no addt treatment neede
- if titer does not double (1:1 - >= ; 1:4), then treat (no EIA test)

condylomata lata
- wart like= ulcer in mouth, anus from secondary syphillis

condylomata acuminata=
- genital warts

#Syphilis

c/b PCN allergy. Risk factor: MSM, HIV, multipl= e sex partners.

Primary syphilis manifests a= s painless genital ulcer.

Secondary syphilis= characterized by rash -- often with involvement of palms and soles. Mucosa= l involvement also prominent. Systemic symptoms often present, generalized = lymphadenopathy. Uveitis and neurosyphilis can also occur.

Latent infection =3D positive serologic test without clinica= l manifestation

Early latent =3D <12 month duration of l= atent infection

Late latent =3D >12 months(based on past serol= ogy results)

Syphilis of unknown duration otherwise

Tertiary syphilis =3D neurologic disease

= - f/u CSF

Dx: RPR or VDRL enzyme immunoassay= .

If negative RPR or VDRL -- order treponemal antibody test=

Primary and secondary and early latent: Ben= zathine penicillin G IM single dose (PCN allergic =3D Doxy 100 = mg BID or tetracycline 500 mg QID x 14 days)

Late latent / syphilis of unknown duration =3D IM benzathine PCN q 1 week = x 3 doses (Doxy 100 mg BID or tetracycline 500 QID x 28 days)

Neurosyphilis =3D Aqueous crystalline PCN G 18-24 million= units daily q 4 hours or by continuous infusion x 10-14 days

Procaine PCN 2.4 millio= n units IM daily plus probenecid 500 mg PO QID x 10-14 days (CTX 2g IM or I= V daily for 10-14 days)

steroids (cortisone= 25mg =3D hydrocortisone 20mg (use this for stress dose) =3D prednisone 5mg= =3D prednisolone 5mg =3D methylprednisolone 4mg =3D dexamethasone 0.75mg)<= br>- if concern immune thrombocytopenia, low plt (if seeing a lot of ecchym= osis and pending workup, 1mg/kg PO inpt okay)
- percarditis
- polymya= lgia rheumatica
- thyroiditis

- if using 7.5+mg/day long term, ge= t vitamin D and calcium levels
HIGH Dose steroids can cause psych issues, e.g. depression, anxiety, psychosis too. Also insomnia, restlessness. Decrease dose.

Normall= y hydrocortisone 50q6 or 100q8
For brain cancer, dex10 push then dex4q6h=

GI UC flare =3D IV solumedrol 40mg daily

Give pepcid, calciu= m, and vitamin d if on steroidsstrep pyogenes
- Expert opinion8 and empirical data2= 1,22 suggest that cellulitis is most commonly caused by Streptococcus pyoge= nes. Our findings are provocative, because TMP-SMX has been considered a po= or empirical choice for the treatment of cellulitis. Recent data show that = S. pyogenes strains may be TMP-SMX=E2=80=93susceptible if low-concentration= thymidine agar is used for testing.23 Our results showing that TMP-SMX and= clindamycin have similar efficacy in patients with cellulitis are consiste= nt with these in vitro data.= strep throat
- amoxicillinstridor =3D whistling when breathing in =3D airw= ay obstruction<= td spellcheck=3D"false" contenteditable=3D"true">st= roke
- DDx: hemorrhage, seizure, complicated, migraine, syncope, headach= e, MS, labyrinthitis, vertivular neuritis, infection, BPPV, hypotension, hy= poglycemia, hypona, alcohol/drug, DKA/HHS, dementia/delirium, encephalopath= y, encephalitis, nerve root compression,

Scoring: ABCD2 ( if &= gt; 5, admit to ICU), high risk of recurrent stroke (>70% cervical carot= id stenosis, or intracranial artery stenosis, or dissection or cardiac valv= e patient), high risk for herniation (large artery occlusion, ICA/MCA, ACA,= large posterior circulation ischemic stroke), post-teneecteplase or post-n= euro interventions

- ischemic: permissive HTN <220/120 for 24-48 = hours, if no tPa, then BP goal <140/90. If tPA <185/110
- Tx: per = MKSAP 19: DAPT for 21 days, then aspirin indefinitely (versus MGH: no need = DAPT. DAPT only for stent/CAD)

- after stroke, hold eliquis to= prevent conversion to hemorrhagic until MRI. Timing of resuming medication= will be based on imaging above to weigh risk of hemorrhagic transformation= with secondary stroke prevention
- if cannot do MRI, repeat CT head wit= hout con in 48 hours.

-if young, then cause congenital heart issue/a= rrythemia, HIT, sickle cell, inherited hypercoag state, syphillis cocaine, = meningitis, endocarditis- CT head
- MRI brain (no contrast)
- CTA head/neck with contrast=
- neuro consult
- urine drug screen
- a1c, lipid, TSH
- TTE fo= r thombus or vegetation with bubble study for ASD/PFO
- duplex ultrasoun= d of internal carotid artery
- neuto check q4h
- accuchek
- aspiri= n 81
- atorvastatin 80
- PT/OT
- bedside swallow, with formal eval=
- tele

hemorrhagic stroke
- repeat CT head in 6 hours
- SB= P 110-140
- swallow eval
- PT/OT
- neuro check q2hstroke
- p= lavix over aspirin if atherosclerosisstroke:
- DWI - bright
- compare with ADC = - black (if not there, shine through/artifact)
- T2 - also structure
= - T1 structure
- DWI Flare - bright (acute won't show bright, vs. subacu= te vs. chronic)

<= /td>subdural hemorrhage
- embolization of middle menin= gial artery (not sure why it helps, but it does) - stops it from oozingsubstance abuse

#Polysubstance abus= e

- ETOH level

- PO thiamine and folate dai= ly

- For alcohol: naltrexone and acamprosate are the most e= ffective medications.

= Naltrexone is contraindicated in cu= rrent opioid use. Caution in cirrhosis, hepatiits, or liver failure (50-100= mg dialy). Caution in depressed patients.

Acamprosate (= 666 TID) -- can be used in alcohol related liver disease. Avoid in severe k= idney impairment

Disulfiram 250-500 daily can be used if= patient is veyr motivated for abstience. Can cause hepatotoxicity.

- For heroin:

Consult suboxone clinic NP = for follow up

<= span style=3D"white-space:pre"> Initiate at 8 mg suboxone once, foll= owed by 4 mg 4 hours later, then 4 mg another 4 hours later if patient not = lethargic

16 total for maintenance

2 mg PRN suboxone if needed

Cannot give = suboxone if opiates are needed

For other withdrawa= l symptoms can schedule:

- NSAIDS

- Atarax

- Immodium

- = Benadryl

- IV ativan PRN

= - Melatonin

- Robaxin

- C= lonidine 0.1 to 0.3

- For smoking:

Varen= ciline is superior to nicotine replacement therapy and buproprion (Avoid in= kidney disease and neuropsychiatric issues)

Nicotine = patches should be given at night to reduce AM cravings

Buproprion is beneficial for concurrent weight gain, but cannot be use= d in those with seizure disorder.

- For methamphetam= ine: Likely some element of meth withdrawal given recent use, ongoing psych= omotor agitation, insomnia within this 1st week of abstinence.

Fl= uoxetine (Prozac) at a dosage of 40 mg per day (reduces short term craving)=

Consider benzodiazepines to manage symptoms of irritabilit= y, sleep disturbance, and anxiety, but should not be continued beyond a wee= k.

Consider modafinil (200 mg x 10 days) -- some evidence o= f milder withdrawal syndrome and reduced craving

Consider d= examphetamine (20mg - 110 mg x 90 days) -- some evidnece of reduction in wi= thdrawal symptoms, and craving.

(https://www.turningpoint.o= rg.au/sites/default/files/2019-05/Turning-Point-Methamphetamine-Treatment-G= uidelines.pdf -- page 40)

SVC syndrome
- p= ossible small cell cancer of lung or agressive non-hodgkin lymphoma
- Tx= : likely responsive to chemotherapy= syncope
- https://www.mdcalc.com/calc/3951/canad= ian-syncope-risk-score (Vtach and death)

- DDx: seizure, stroke, sub= clavian steal, PE
- consider event monitor

- no prodrome =3D more= likely cardiac (arrhythmia, structural, tamponade, dissection, brady/tachy= , AV block)

- reflex:
- vasovagal (has trigger, prodrome o= f warmth / dizziness / nausea) -- midodrine can also reduce vasovagal synco= pe episode by 43% (but first try without)
- if vasovagal unclear,= tilt table
- carotid sinus syncope =3D test with sinus ma= ssage
- situational (sneezing, cough,

- orthostatic:=
- SBP decrease by 20 or DBP drop by 10 within 3 minutes of stan= ding (within 15 second =3D immediate, classic =3D <3 min, delayed = =3D >3 minute; dilt table only if suspect delayed orthostatic)
= - check any cardiac meds
- can be due to autonomic failure from = parkinson, DM, amyloid, lyme, syphillis, B12, opioids
- Tx: fluid= intake, more salt, midodrine 5-20mg TID if neurogenic orthostatic

<= br>vasovagal =3D noxious stimuli, fear, stress, heat overexposure, or prolo= nged standing
situational syncope =3D cough, micturition, defecati= on, or swallowing
carotid sinus hypersensitivity =3D head rotation, shav= ing, or use of a tight-fitting neck collar

- orthostatic vitals
- EKG
- TTE<= br>- blood sugar, a1c
TSH
- B12
- urine drug screen
- lip= id
- PT/OT
- admit to tele

- consider EEG

#syncopa= l episode:

differentials include mechanical, metabolic, reflex sy= ncope (vasovagal, situational, carotid sinus) , orthostatics, cardiogenic, = neurologic. Most likely is { } {has/does not:18049} high risk symptoms incl= uding palpitations, afib, intoxication, bleeding, focal deficits, post-icta= l state, known cardiac arrhythmia, structural cardiopulmonary disease. {Les= s} likely neurologic given normal head CT without evidence of stroke, and l= ack of seizure like symptoms. Rare causes of syncope include: DM (autonomic= dysfunction), amyloid, spinal cord injury, ETOH chronic, meds, syphilis, B= 12 deficiency; extremely rare causes include PD, lewy body, Shy Drager.&nbs= p;

-EKG shows:

-Orthostatic vital signs

-Echo

-UDS, CMP, CBC

-Imaging: {CT head}

{-S= PEP if c/f amyloid, RPRP, b12}

-consider zio patch outpatie= nt

{-Can treat with midrodrine 5-20 TID, or fludrocor= tisone 0.1-0.2mg daily. Droxidopa for PD associated orthostatis.}

{-Concern for Neurologic Seizure, stroke/ TIA, subclavian steal) +Tongue b= iting, urinary fecal incontiennce, stroke TIA.}

{-EEG for seizure= }

{-CT MRI/MRA for stroke}

T1DM
- measure GAD65 a= b and IA-2 Ab
- 20% has will get another autoimmune diseasehtacrolimus: increases K = ; (level 5-8 for kidney transplant; 4-5 for heart and liver)
CKD: bicarb= slows down CKD progression
if proteinuria and ARB doesn't help, add fin= erenone or spirinolactone

tacrolimus lab: get 12 hours from night do= se, right before mornign dose= takayasu arteritis
- stenosis and inflammation of aorta a= nd large vessels (subclavian, common carotid, renal arteries)
- Sx: bila= teral arm claudication (pain/ache/fatigue of muscle worse with activity, be= tter with rest)= t= amponade / pericardial
- Beck's triad for tamponade: low BP, JVD, muffle= d heart sounds. pulse paradoxus (decrease SBP >10 mmHg when inhali= ng; get BP when only exhaling, then decrease until hear all the time)
- = EKG shows low voltage, only precordial leads may sometimes show electrical = alternans; echo shows diastolic collapse of RV.
- rate of accumulation m= ore important that size
- Tx: ensure fluid (250-500cc boluses). no= beta blocker, avoid positive ventilation. Remove drain when <50cc= /daytardive dyski= nesia
- lip and face twitching
- after long use of antipsychotic/anti= nausea or metoclopramide (all Dopamine D2 receptor blocker)
= - Tx: valbenazineTB
- pleural TB and lymphadenopathy can be TB.TBI (traumatic brain injury) paroxysmal sy= mpathetic hyperactiviy syndrome
- propranolol 20mg TID, neurostorming (f= ever, tachy)
- baclofen to help with dystonia due to TBI; bromocriptine = also for dystoniatest tips:
- if new symptoms for someone with chronic issue, need inves= tigate
- choose answer that helps actually diagnose (not just helps with= prognosis)<= td spellcheck=3D"false" contenteditable=3D"true" class=3D"sorting_1">thicke= ned gallbladder
- need MRI/MRCP
- gallbladder cancer asymptomatic.&nb= sp; Treatment is choleystectomythis is a new clinical pearl MELD Na = (UNOS/OPTN) (mdcalc.com)= thrombocytopenia (low plt)
- score: 4T for HITT (if hepar= in), DIC criteria
- labs: HIV, HCV, varicella, CMV, EBV, parvo, tickborn= e, B12, folate, DIC, TTP, haptoglobin, LDH, DAT, d-dimer, fibr= inogen,
- other causes: some bleeding? ITP, HUS, preclampsiia, hyp= erspleen. If lupus, add anticardiolipin, anti beta2,
- DDx: <= br>
pancytopenia
- labs: HIV, HCV, HBV, CMV, EBV
- CRP, ESR
- D= IC screen, EPO level
- nutrition work up: iron/ferritin, B12, folate, zi= nc, copper
- autoimmune workup: antiphospholipid (anticardiolipin IgG, I= gA, IgM, beta 2 glycoprotein, IgA, IgG, IgM, anti-lupus anticoagulant, ANA = panel (SSA, SSB, RF, anti CCP, ANCA, ANA, anti-smith, ds-DNA, SCL 70), cryg= lobulinemia
- hemolysis labs: LDH, reticulo count, peripheral blood smea= r, haptoglobin, UA, direct and indirect coombs
- U/S abdomen for splenom= egaly

b12, folate, iron panel, zinc, copper, HIV, EBV, CMV, hepatitis panel, smear= , H pylori

-if fibrinogen < 150,and= need any procedure/biopsy, need cryo

#Thrombocytopenia

Question of whether= this is due to decreased production, increased destruction, or sequestrati= on.

To evaluate for decreased production: ma= y be due to sepsis, but would also evaluate for the following

- HIV, HCV

- Parvovirus

- B12, folate, copper,= ETOH

- Possibly due to malignancy: leukemia, MDS, PMF, apl= astic anemia

To evaluate for increased destr= uction:

- HIV, HCV, H.Pylori, HSV, VZV, CMV, EBV

= - ITP, SLE, RA, CLL, HIT

- Drug induced

- MAHA --= DIC/ TTP/ HELLP

- Shearing / aggregation -- CVVH, CPB, IAB= P, vasculitis, hemangioma (kasabach Merrit)

= For sequestration:

- Evaluate for splenomegaly, massive transfusi= on, hypothermia, gestational

- Concern for hemolytic anemia (concurrent Hgb, Platelets) -= - check LDH/haptoglobin/bili/ DAT (AIHA), retic count

- Per= ipheral smear -- check schistocytes -- coags, d-dimer, fibrinogen

- Consider ANA

- IF > 60 yo, splenomegaly, or sys= temic sx, consider BMBx to r/o MDS, AA leukemia, infiltrate

- Rule out pseudothrombocytopenia -- platelet clumping due to EDTA, can or= der platelet count citrate

If ITP -- severe = bleeding: IVIG, methyl pred 1g/d IV x 3 days >>> amicar

1st line: dexamethasone 40 mg x 4 days

2nd line= : Rituximab

If HIT -- anti-PF= 4 heparin complex Antibodies binding and activating platelets. Presents 5-1= 0 days after exposure, decreased platelets by 50% with the nadri 40-80k, th= rombosis in 30-50%.

- 4T score of ***. If >4, dc heparin= and check anti platelet factor 4. Then serotonin release assay

- Argatroban in the meantime

#Thromboti= c Micrangiopathy

Small vessel irregularities causing microt= hrombi.

Consider MAHA (decreased hemoglobin, elevated LDH, = decreased haptoglobin, positive eschistocytes, negative DAT) -- TTP, HUS, a= typical HUS, drug-induced (immune mediated -- includes gemcitabine, oxalipl= atin, quetiapine, quinine -- n/v/d, AKI, abd pain, dose dependent-- include= s everolimus, plavix, cocaine -- subacute fatigue, HTN)

#DIC (increased PT, D-dimer, decreased fibrinogen)

<= div>- DIC Score: ***

- Treat underlying cause

- P= latelet transfusion if < 10

- Cryo if fibrinogen < 10= 0

- FFP if INR > 2

- Soft or puree diet to avoid GI bleeding

- Mirala= x senna to avoid GI bleeding

- Fall precautions

= thryoid nodule:
- if > 1cm, fine needle biopsy or = if <1cm and risk factors for cancerthyroid nodule
- thyroid U/S

Hyperthyroi= dism-
- S&S: lid lag, tremors
Methimazole has side effect of a= granulocytosis (patient will sore throat). Low wbc . Check wbc in 2 wee= ks.

Subclinical hyperthyroidism: Tx if symptoms or TSH > 0.= 1uU/L

- if 1st trimester, PTU (SE of liver toxicity)

Graves -= pretibial myxedema (sugar deposit in lower legs causing swelling), goiter;= if has eye symptoms (don't do radioactive iodine!, worsens eye symptoms)

thyroid storm: can be normal thyroid level; a clinical diagnosis.= S:S fever, cardiac decomp, delirium/psychosis after surgery, infection.&nb= sp; Preferred treatment is PTU, steroid, betablocker

patients with g= races can have isolated R heart failure.= thyroidtoxicosis
- esmolol drip, methimazole 20 = q6h, solucortev IV

tinea pedis: topical terbinafine or miconazole cream BID 4-6 we= eks
tinea corporis: terbi= nafine 1st line, miconazole 2nd line. BID for 4-6 weeks

<= /td>

Tokyo Guidelines for acute cholangitis

Tokyo guidelines for acute cholecystitis

toxic shock / SJS / TENS

Toxic shock (sta= ph aureus exotoxin! + skin scuffing from tampon + nasal packing + surgical = wound)
- Sx: palm and sole rash
- Tx: clindamycin (theoretically prev= ents toxin being made) and vanc/oxacillin/nafacillin to kill the bacteria. = Need LOTS of fluid replacement.
= TPN
- no TPN prior to 7 days of acute illness

= Transaminitis:R Fact= or for Liver Injury (mdcalc.com) for cause
AST/ALT >2:1 alco= hol and rhabdo

#Hepatocellular injury

R Factor > 5 suggestive of hepat= ocellular injury. NALFD fibrosis score for steatosis ***.

<= br>

Ischemia less likely given AST/ALT elevation is not in the th= ousnads. ETOH likely given 2:1 ratio of AST:ALT. Viral infection is possibl= e. Other differnetials include autoimmune hepatiits, celiac disease, hemoch= romatoiss, A1AT ( can occur without significant lung involvement) Wilson's,= and congestive hepatopathy given RHF. Medications known ot cause hepatocel= lular injury include Tyleonol, augmentin, amiodraone, allopurinol, cabramaz= epine, fluoxetine, heparin, INH, labetalol, lisinopril, losartan, nitrofura= ntoin, NSAIDS, phenytoin, ketoconazole, protease inhibitors, staitns, sulfa= drugs, trazodone, VPA.

- CMP daily

- Viral hepatitis panel + total Hep B antibody

- CM= V, EBV, VZV, HSV for other viral causes of transaminitis

- = Anti TTG, total IgA for celiac's. Consider endomysial given high specificit= y if this is positive.

- f/u iron panel nad ferritin Fe/TIB= C:> 45% and ferritin > 200 should warrant HFE testing (often diagnose= d in those 40+, with women manifesting symptoms later than males)

- Ceruloplasmin, urine Cu for Wilson's (hemolytic anemia from sudden relea= se of copper and altered mental status supports this)

- ECH= O for evaluation of congestive hepatopathy

- ANA, ASMA, AMA= , LKM1 serologies, SPEP for AIH evaluation

- RUQ US for fat= ty liver

- UTox for cocaine, ecstacy, PCP

Ischemia likely given recent shock, cardiac arrest, = history of Budd Chiari. Can consider rarer causes such as autoimmune hepati= tis, acute Wilson's, HELLP syndrome, alcoholic hepatitis, malignant infiltr= ation.

- LDH -- ALT:LDH ratio <1.5 suggestive of ischemi= a/APAP toxicity over viral hepatitis.

- Continue to monitor= bilirubin -- often will see a peak in 1 week later after a 48 hr acute ris= e in ALT/AST.

- Acetaminophen level

- Hepat= itis panel, total hepatitis B antibody, HSV, VZV, EBV, CMV to evaluate for = acute viral infection

#Choles= tatic injury

R Factor < 2 with elevated alk phos and bili. Ddx= includes bile duct obstruction (malignancy, ascneidng cholangitis, PSC, PB= C, chronic pancreatitis with strictures), cirrhosis, medications.

- Hepatitis panel

- RUQ U/S for obstruction

- An= ti-Mitochondrial antibodies

#Infiltrative pa= ttern of liver injury

Alk phos elevated to ***. Ddx includes sarc= oidosis, granulomatous diseases, amyloidosis, malignancy. Alk phos is als o= found in bone (bony mets), intesitns (increased in SBO).

- = GGT -- if high concern for liver source -- test fractionated alk phos (bone= gut hepatic)

- Consider SPEP

Indi= rect hyperbilirubinemia: consider Gilbert's, hemolysis, resorption of large= hematoma.

transfusion criteria

HGb:- >Hgb 9 in critically ill
- >8 with preexisting CAD, ACS
- a= ny time >1.5L blood loss

leukoreduced (decrease WBC) - all at UCI= is leukoreduced: if had febrile non-hemolytic reaction before
irradiati= on (inactive lymphocytes): if had stem cell transplant, on immunosupressive= s, cancers, or immunodeficient
washing (remove plasmta protein, electrol= ytes, Ab): severe allergice reactions, IgA or haptoglobin deficient, pt at = risk of hyper K
volume-reduced (remove plasma): thalassemia major, sickl= e cell, CHF

Plt:
- >100k if neuro or eye surgery
- >= 50k for surgery or active bleeding
- >20k if 100.4F and invasive proc= edure
- >10k normal
- hold anticoags, antiplatelet if Plt <50k<= br>
order ionized calcium if lots of transfusion; Serum Ca can be n= ormal. Muscle spasm =3D hypoCa. Citrate binds ionized calcium (= active calcium).

TRALI
- HLA or neutrophil-specific = antibodies in multiparous donors that bind to and activate recipient leukoc= ytes in the pulmonary vasculature

TACO
- respiratory d= istress within 6 hours of transfusion, positive fluid balance, elevated cen= tral venous pressure, and radiographic findings of pulmonary edema

a= cute hemolytic transfusion reaction
- fever, dyspnea, hypotension, flan= k pain, and pink-colored urine appearing during or shortly after a transfus= ion.
- Tx: immediate discontinuation of the transfusion, volume exp= ansion, and supportive care.= trauma

Differential includes concussion, pneumothorax, pulmonary contusion, = rib fracture, extremity sprain. Low suspicion for intracranial hemorrhage, = SDH, tSAH, or skull fracture. Patient is neurologically intact in setting o= f low speed traumatic mechanism, no vomiting or difficulty ambulating. Doub= t spinal fracture or c-spine injury, given no spinal point tenderness and f= ull ROM of neck. Doubt hollow organ injury, acute traumatic abdomen, or sig= nificant internal hemorrhage, given reassuring abdominal exam, no ecchymosi= s/abrasions, vomiting, or bloody stools. Doubt significant thoracic or aort= ic injury, no chest wall tenderness, hypoxia. Low suspicion for extremity f= racture.

High risk populations: age >55, antico= agulation, pregnancy > 20 weeks.

NEXUS chest cr= iteria all absent - normal CXR, no distracting injury, no chest wall, stern= al or scapular tenderness, no significant mechanism (fall > 20 feet, MVC= > 40 mph).

NEXUS c-spine criteria all absent - no focal neuro= deficit, no midline tenderness, no ALOC, no intoxication, no distracting i= njury.

Canadian head trauma criteria all absent - no blood thinne= rs, no seizure, GCS > 15, no signs of basilar skull fx, no vomiting, age= < 65, no retrograde amnesia, not dangerous mechanism ( fall > 3 feet= , MVC ejection, ped vs auto).

traveler's diarrhea prophylaxis:
= - rifaximin recommended for patients with immune compromise, IBD, CKD
- azithromycin if fever >101F after obtaining culturestricyclic antidepressants, TCA e.= g. nortriptyline
- careful with people with heart disease as associated = with arrythmia, heart block, sudden deathTTP more neuro status affected, less kidney
HUS= nore renal, less neuro status
DIC - cancer or infectiontube feeding
- tuve feed <4= 8 hours reduces mortality
- no early feeding if in shock
erythromycin= (prokinetic - better than metoclopramide)
- residual (content in stomac= h when feeding stopped) <500 okay; if more, ensure head of bed > 30, = erythomycin or metoclopramid, advance to post-pyloric or into jejunum (if v= omiting)
- gastric okay for intermittent or continuous feed (no changes = in outcome)
- post-pyloric only for continuous feed 3D""

tumor lysis TL= S
- give lots of IV hydration (and lasix to enhance urine flow)
- ura= te, K, phos really high
- IV rasburicase for all high risk (bulky diseas= e, high leukocytosis count, high urate or LDH, very bad CKD), or if rapid d= ecreasing urate level is neededUGI GI Bleed
Glasgow-Blatchford Bleeding Score (GB= S) (mdcalc.com) - whether to discharge or admit
- DDx: esophage= al varice, mallory-weiss tear, peptic ulcer, esophagitis, neoplasm
- nee= d endoscopy
- test for H pylori
LGI Bleed
- RBC nuclear scan if pa= tient unstable. Need colonoscopy
- famotidine useless for UGI blee= d (only do PPI)
- if unstable for colo right away, CTA

GI B= leed:
- PPI BID
- retic count, iron panel/ferritin
- 2 large bore = IV

- admi= t to telemetry
- no anticoag, antiplatelet, NSAID
- CBC, CMP, PT/INR,= albumin, BUN, Cr
- CBC q6h
- type and screen if hemodynamic stable, = severe bleed, or high risk
- orthostatic vital sign (moderate blood loss= )
- 2 large IV bloores (16 gauge or larger)
- IVF bolus and maintenan= ce fluid
- NPO
- SpO2 goal 92%
- consulted GI
- protonix = 40mg IV BID
- transfuse if Hgb < 9 in elderly, CAD, <8 in CVD and = signifant UGI bleed

- recommend intravenous fluid r= esuscitation with the goal of normalization

of blood pressure and= heart rate prior to endoscopic evaluation/intervention

- discuss= with the patients cardiologist regarding safety of holding ASA, plavix, NO= AC*

- trend H/H serially and transfuse as needed

- bloo= d transfusions should target hemoglobin =E2=89=A5 7 g / dl, with higher hem= oglobins targeted in patients with clinical evidence of intravascular volum= e depletion

or comorbidities, such as coronary artery disease

- check iron studies, B12, folate

- check PT/INR if not al= ready obtained

- please acheive goal INR in acute GI bleeding pat= ients of 2.5 or below

- transfuse platelets if <50

- Plan for diagnostic colonoscopy and possible EGD tomo= rrow (this is an add-on case and therefore there is no scheduled time) = ;

- Clear liquid diet today

- 4L of Golytely bowel prep= starting tonight. After finishing this, give additional bowel prep until B= M are clear

- Make NPO at midnight except bowel prep and essentia= l medications

<= /td>Ultrasound
Nerve like a flag (hypoechoic)Tendo more lines in between - fibrils (tendons are anisotrophic . If you = tilt then becomes darker)
15+ mhz for nerve
Cartilage anachoic
If = dopplwr flow in synovial fluid, likely respond better to steroids or ra med= s (inflammation)
Cellulitis lights up on the surface. Edema does not on = doppler due to vasodilation there
Ra synovial is normally 1 cell thick.&= nbsp; Ra had more.Ultrasound
- compare liver echo to kidney for cirrhosis
- 20 hounsfi= eld unit spleen to liver difference on ct also
- portal vein flow toward= s transducer 10 - 20 is normal
- >125 cm/s ICA is moderate stenosisultrasound
- EP= SS: anterior mitral valve to IV septum: if <8,mm, no systolic dystunctio= n (EF not <55%)
- a wave not present in Afib

ultrasound
- Kidney: mid axilla= ry, T4-6. L kidney even more posterior and towards head (cephalad)

= - Cardiac: EPSS (e-point septal separation, i.e. mitral valve to septum) &g= t;7mm =3D EF < 50% (87% sen; 75% spec)

- Gallbladder: thicknes= s >3mm vs >4mm =3D nonspec gallbladder disease

=E2=80=82=E2= =80=82=E2=80=82=E2=80=82=E2=80=82=E2=80=82- pericholecystic fluid + wall th= ickness + distention (>10cmx4cm) =3D 100% acute chole

=E2=80= =82=E2=80=82=E2=80=82=E2=80=82=E2=80=82=E2=80=82- gallstones + suspect acut= e chole =3D dx acute chole

=E2=80=82=E2=80=82=E2=80=82=E2=80=82= =E2=80=82=E2=80=82- X-7 =3D 7cm right of subxiphoid, lying left side, hold = breath

- CBD > 6mm =3D choledochol

- AAA >3cm =3D= mild (5cm =3D 20% of lifetime rupture; any baseline size, but >0.5cm in= crease in 6 months =3D high risk of rupture)

- IVC: eval 2-3cm from RA

= ultrasound:
- lu= ng use linear and then use abd probe (anterior, lateral, and posterio= r)
- a lines normal
- pneumothorax: no lung sliding; M mode sho= ws barcode sign instead of sea shore sign
- b lines: edema / blood / col= lagen /transudative/exudative: more than 3 IS pathology.
- posterior vie= w better for edema for HF 3D""

<= br>

=
ultrasound
E is diastolic filing A is late di= astolic atrial kick
A > E: early diastolic dysfunction
E > a = =3D normal, pseudonomal. If E/a > 3:1 then restrictive diastolic r= elaxation
E/e' <8 normal; > 15 is elevated

RV function =3D = do TAPSE:
4 view chamber, normal TAPSE > 16mm

RV free wall= thickness < 5mm; > 10mm is pathologic

gallbladder: <=3D 3m= m thick normal, can be thicker after eating 3D""

= ultra= sound
renal
- don't order renal u/s for pyelo (clinical diagnosis; on= ly for complicated pyelo with abscess/stone) or infarct
- inptiatnet ren= al: just for hydro; then if imaging, CT for further (cancer, stricture, obs= truction -- do not rely on ultrasound for cause rule out)
- mass should = be CT, not ultrasound
- ultrasound good for known stone; gold standard i= s non-contrast CT (uric acid stone still show on CT)
spleen: <12
-= ultrasound only for size splenomegaly
- or for lymphoma
liver:< 1= 6
- only if history of cancer/liver metastasis (but CT much better)
-= outpatient: screening for steatosis (how bright the liver is - bright is b= ad; normally sould just be very slightly brighter than kidney/shouldn't be = able to tell); cannot rule out cirhossis - looking for border nodularity, t= hen parenchema for echotexture like porcelain (portal hypertension)
- ou= tpatient: appropriate: screening for HCC q6months (then confirm with MRI)- simple cyst growing is benign.
- abd limited: without kidney
panc= reas: nothing (limited sensitivity for anything)
- don't get CT imaging = for acute pancreatitis; should be 1 week-10 days after initial symptoms if = not improved)
gallbladder
- acute chole and CT now complimentary (if = ultrasound positive, straight to HIDA (most specific and sensitivity), not = CT); but ultrasound better for seeing stones(as some don't show on CT)
-= gallbladder wall sensitive but not specific (pancreatitis, ascites can cau= se it; wall takes in water quickly);
- gallbladder distension sensitive= (if flattened, not likely), but not specific
biliary tree:
- can see= CBD, but not know where it's due to (i.e. should be for screening) ; CBD n= ormal 0.6-0.8; if after chole, than 1.0
- if CT done already, go t= o MR (should not go back to ultrasound)

https://www.raducation.xyz/<= br>
uremia
= - echinocytes (spicules on blood smear; vs. acanthocytes projections are la= rger) 3D""

= urina= ry incontinence
- stress =3D decreased urethral sphincter tone and ureth= ral hypermobility: leak with cough, sneeze
- Tx: exercise and pes= sary (if menopause, can also try estrogen cream; NOT oral)
- urge = =3D detrusor overactivity: sudden urge to pee
- Tx: train to hold= , oxybutynin (Ach blocker - relaxes bladder), mirabegron (beta agonist)
= - overflow =3D impaired detrusor contractility or bladder outlet obstructio= n: incomplete emptying, dribbling
- Tx: timed urination; bethanec= hol (Ach agonist) if underactivity<= /tr>UTI

Complicated: outside of bladder.

<= br>- Tx duation: uncomplicated 5 days, complicated 7 days, CAUTI: 7 days, p= yelo: 14 days
- Tx:
- 1st: bactrim BID x3 day (do not use if = used previously), Macrobid (nitrofurantoin) 100mg BID 5 days (do= es not work for pyelo)
- 2nd: ciprofloxacin 250mg BID x3 days, Au= gmentin 500-125 BID 7 days

2nd most common in young female: Sta= phylococcus saprophyticus (gram positive in clusters)
most common: ecoli=

asynmptomatic - pregnant;

pyelonephritis
- most com= mon Ecoli. If pregnant, must admit; else mild-moderate can be outpati= ent
- Tx (outpt): cipro 500mg BID for 7 days, levofloxacin 750mg QD for = 5 days, Bactrim DS BID for 14 days
- Tx (inpt): ceftriaxone 1g daily, le= vo 750mg IV daily, ciprofloxacin 400mg BID, cefepime 1g TID. IF enter= ococcus, ampicillin 2g TID+gentamicin 1mg/kg TID, zosyn 4.5 TID, ampicillin= -sulbactam Unasyn 3g QIDpsuew

pyridium (phenazopyridine) relieve= s symptoms from UTI

- enterobactter, staph saprophyticus, stre= p agalactiae; if struvite cyrstal (coffin-lid), then likely proteus; (also = can be klebisella, or pseudomonas as these secreate urease that create stru= vite stones)
- UTIs occurring in hospitals and long-term care facil= ities frequently involve a more varied group of organisms (such as Enteroba= cter, Providencia, Morganella, Citrobacter, Serratia, and Pseudomonas<= td spellcheck=3D"false" contenteditable=3D"true">

#Uncomplicated UTI: P= atient endorses frequency, urgency, dysuria, malaise, incontinence, nocturi= a, suprapubic tenderness, fever, chills/ rigors, pelvic / perineal pain. +N= itrites are positive with enterobacteria. Differential includes vaginitis, = urethritis, structural abonrmality, PID, nephrolithiasis.

-= NFT 100 BID x 5 days (avoid if CRCL<40)

- Bactri= m DS BID x 3 days for females x 7 days for males (Hooton 2019) (empiric if = resistance is >20% E coli to nitrofurantoin)

- Fosfomycin 3g x 1 day

Alternatives is augmenetin x 7 da= ys

#Complicated UTI: UTI and = systemic symptoms -Fever 99.9F, Chills, Flank Pain, CVA tenderness, Pelvic = Pain in Men, special populations: Pregnant woman, Renal Transplant.

- Outpatient-- ciprofloxacin 500 mg BID x 5-7 days OR levofloxacin= 750 mg x 5-7 days OR bactrim DS BID x 7-10 days {susceptibilities recommen= ded}.

- Inpatient: CTX or cefepime

- Add va= nc if concern for GPC infection on uringe gram stain

- Add = Meropenum if concern for ESBL coverage (marino trial)

- Ren= al ultrasound

- f/u urine cultures. bcx

#Catheter associated UTI: Signs of UTI with no other identified sourc= e of infection AND urine culture with one uropathogenic species > 10^3 C= FU/ml from single catheterized urine specimen ( catheter in place > 2 d)= _ OR midstream voided specimen from patient whose catheter was removed in p= revious 48 hours.

- CTX or FQ AND VANC for 7 days

- Remove cather ASAP

- Repeat UA/UCx

<= /div>

Fungal -- common colonizers, only treat if symptoms or neutropeni= c or before uro procedure

If resistant C glabarata or kruse= i use conventional amphotericin

#Asymptomati= c bacteriuria (or bacteriuria without symptoms) should NOT be treated in th= e absence of symptoms except in pregnant women, those with renal transplant= in first 3-6 months, and prophylaxis for invasive urologic procedures).&nb= sp;

- ESR, CRP

VA workflow
Admissions: June VA Ward Team= s Board 23.xlsx (sharepoint.com)
ED Board: Emergency Department Integration Softw= are (va.gov)v= ancomycin

if MRSA, vancomycin MIC >2, needs daptomycin or linezol= idVascular insuf= ficiency
- if very bad PAD, can be false normal (if neuropathy, diabetic= s)vasculitis
-= Sx: hemopytsis, kidney pain, scleritis, SOB, fatigue,
- labs: ANC= A, complements<= td spellcheck=3D"false" contenteditable=3D"true">va= sotec over metoprolol if okay (enalaprilat)Vbg to abg co2 decrease by 6.
Ph increase by 0= .05

Nonanion gap metabolic acidosis. Calc winters formula. Ord= er urine cl, k, na. Urine osm gap

Rta 1 cannot make h+ to urine so c= annot bind with nh3 to make nh4+. So anion gap is high. Ph >5.5
Rta 4= cannot make nh3, so also anion gap high. And ph<5.5 (still H+ in urine)=

Both above, urine osm gap would also be negative or <100
Then= look at serum K for type 1 vs type 4(high)

Rta 2 anion gap negative= as just cannot absorb bicarb

Ua protein is albumin. Urine spot prot= ein is everything

Rta1 cannot get rid of h+, so all acidic goes = to bone (good buffer in body for acid) and thus bone calcium and phosphate = gets released - causes calcium phosphate stones.
Ph increase to 6.= 5 with potassium citrate then stop. Else more alkaline gets likely stones.<= /td>venous stasis- Sx: edema, varicosities, eczematous changes, brown pigmentat= ion from hemosiderin deposition, lipodermatosclerosis (fibrosis of subcutan= eous tissue), atrophie blanche (pale plaques of scar tissue)
- compressi= on therapy (but if ABI 0.5 or less, contraindicated)
- venous stasis ulc= er =3D irregularly shaped and shallow, weep serous fluid. , and evidence of= healed ulcers. 70% of all leg ulcersvolume overload
- IV diuretics for all cases- strict I/O

If inadequate response to diuretics, add vasodilator = if SBP > 100
vasodilator nitroglycerin 0.4mg tab x3 q5min, and nitro = gtt 20mcg/min
- labs q15m, then q30 mi, then q4

if also low cardi= ac output (low CI) =3D i.e. narrow pulse pressure, AMS, prerenal azotemia, = cool extremities, decreased urine, poor response to IV diuretics
- admit= to ICU/CCU
- if on betablocker, then milrinone 0.125mcg/kg/min and titr= ate), if no beta blocker, dobutamine 2.5mcg/kg/min or milrinone.

VRE (vancomycin= -resistent enterococci)
- Tx: linezolid, daptomycin, tigecycline

=

warfarin = bridge before surgery
- if clot within 3 months or CHADSVASc 7+, else ho= ld 2 days prior
<= /td>warm hemolytic anemia
- postiive DAT
if Hgb < 7, blood transf= usion likely won't match, but still transfuse
"Therefore, if crossmatch-= compatible units cannot be identified, type-specific blood should be slowly= transfused and the patient closely monitored. Although the autoantibody wi= ll shorten the survival of the transfused cells, the hemoglobin level will = often remain improved for several days, providing significant clinical bene= fit."
- prednisone and rituximab to get rid of the antibodiesweight loss:

- C= achexia due to cancer (likely because of TNF=CE=B1 and other cytokine produ= ct) cannot be significantly reversed by more aggressive or invasive methods= of nutritional support, including enteral (or parenteral) nutrition, and t= hese interventions do not improve morbidity or mortality.

- Meges= trol may enhance appetite and promote some weight increase but is associate= d with adverse effects (such as risk for thrombotic events); for those who = do gain weight, neither mortality nor quality of life is improved.

1. Focus on portio= n control. Only a quarter of the plate should be carbs. The other quarter s= hould be protein. The other half should be vegetables with some fruit on th= e side. You can have one serving of dairy on the side. Refer to ChooseMyPla= te.gov. Other options include meal replacements such as Jenny Craig, Weight= Watchers, SmartOne, or Lean Cuisine. Your daily calorie goal should be to = reduce to 1200-1300 calories a day

2. Try intermit= tent fasting

The 16/8 method: Also called the Leangains pro= tocol, it involves skipping breakfast and restricting your daily eating per= iod to 8 hours, such as 11 am - 7 pm. Then you fast for 16 hours in between= .

3. Try meal replacements. You can try to drink a= protein shake such as a Premier Shake or SlimFast for lunch after your int= ermittent fasting ends.

4. The largest sourc= e of excess calories is from liquid calories. Examples are soda, alcohol, j= uice, milk. Try and reduce and eventually eliminate these. Instead try to d= rink at least 2-2.5 liters or 67-84oz of water a day.

<= div>5. Try to limit carbohydrate intake. Examples are white rice, potatoes,= pasta, bread, french fries, chips. These have a high glycemic index which = means they will make your blood sugar high quickly and also plummet quickly= . This drop will make you hungry again more quickly.

6. Decrease desserts. Try snacking on vegetables like microwaved f= rozen peas before your meals to limit your hunger and as a source of fiber = to trap cholesterol, or as a snack if you are craving desserts.

7. Increase servings of vegetables and fruits. Goal is = 6-7 servings a day

8. Besides diet modifications, = try to exercise 30 minutes daily at least 5 times a week. You can try walki= ng, swimming, or even biking. Your step goal should be around 8000 a day.

9. Please call weight management at UCI for a free = class (949-824-8770)

10. Try downloading Noo= m -- an app that helps with counseling to reduce appetite.

11. Alli (orlistat) is an over the counter medication you ca= n purchase. You can take 2 pills (120 mg) with your main meals to prevent f= at absorption. It can cause diarrhea with fatty meals. If you take this, ma= ke sure you take a multivitamin at night to make sure you are getting enoug= h vitamins.

12. If you are diabetic or predi= abetic, consider starting metformin, liraglutide (Victoza), semaglutide (GL= P1) for added weight loss.

13. Talk to your = doctor to see if you qualify for Qsymia or Phentermine

14. If your BMI >40 or if you have comorbidities like OSA and HTN a= nd you have a BMI >35, ask your doctor about bariatric surgery.

Sleeve gastrectomy is accomplished by excising the part of= the stomach along the greater curvature, creating an approximately 85% red= uction in size; similar to gastric bypass, it results in restriction of cal= orie intake via a smaller stomach and hormonal (GLP-1 and related hormones)= appetite suppression. The smaller gastric surface area also results in les= s production of ghrelin, an appetite stimulant.

wound
- avoid d= ry gauze as when pulled off, will also remove good granulation tissue
WPW
- do not= use calcium channel, b blocker or digoxin if also Afib; use procainam= ide if pt has Afib and WPW
- Afib with WPW is risk factor for Vfib=

- if AVNRT - use Ca channel blocker and B blocker to prevent re= current AVNRT
AVNRT =3D p wave buried in QRS or right after; AVRT = =3D sees an RP interval